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Medicare ABNs (Advance Beneficiary Notice)

The Advance Beneficiary Notice is… a written notice which a physician (or supplier) gives to a Medicare beneficiary is intended to inform a beneficiary before he or she receives specific services (or items) – that otherwise might be covered by Medicare – that Medicare probably will not pay for them on that occasion designed to allow the beneficiary to make an informed decision whether to receive the services or items for which he or she may have to pay out-of-pocket, or through other insurance

Summary of Exclusions from Medicare Benefits: Personal comfort items Routine physicals and most screening tests Most vaccinations Routine eye care, eyeglasses and examinations Hearing aids and hearing examinations Cosmetic surgery Most outpatient prescription drugs (unless patient has Medicare D) Dental care and dentures (most cases) Orthopedic shoes and foot supports Routine foot care Health care received outside the USA

More Exclusions… Services by immediate relatives Services required as a result of war Services under a physician’s private contract Services paid for by a non-Medicare government entity Services for which the patient has no legal obligation to pay Home health services furnished under a plan of care, if the agency does not submit the claim Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, furnished to an inpatient, unless furnished under arrangements by the hospital

And… Items and services furnished to a resident of a skilled nursing facility (SNF) or part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF Services of an assistant at surgery without prior approval from the peer review organization Outpatient occupational and physical therapy services incidental to a physician’s services

How do I decide if an ABN is needed? The following information is from “What Doctors Need to Know about the ADVANCE BENEFICIARY NOTICE (ABN)” published by the Medicare Learning Network

Will Medicare deny payment for this service? No, I do not expect Medicare to deny payment I don’t know. I never know what Medicare will deny Do not give any ABN. Do submit a claim to Medicare. If Medicare pays, you may collect charges from Medicare, and any coinsurance & deductible from the patient. If Medicare denies payment for medical necessity, you may: Provide additional documentation of medical necessity Appeal on the basis that the service should be covered Appeal on the basis that you could not reasonably have been expected to know Medicare would not pay If Medicare denies payment based on a statutory exclusion or failure to meet technical coverage requirements under the program benefits section of the law, YOU MAY COLLECT FULL CHARGES FROM THE PATIENT.

Yes, I have a genuine reason to expect Medicare to deny payment. Ask, “On what basis do I expect Medicare to deny?” MEDICAL NECESSITY Denial as “not reasonable and necessary” Do give an ABN. If the patient receives the services or items, you must always submit a claim to Medicare (called a “demand bill”) If you do not submit a claim you violate the mandatory claims submission provision, which can result in sanctions EXCLUSIONS & TECHNICAL DENIALS All other exclusions from medicare benefits, and failure to meet technical coverage requirements Do not give an ABN. You do not need to submit a claim unless the patient demands it If you do not submit a claim, you may collect full charges from the patient. And….

When (or If) you submitted a claim,

If Medicare Pays: Collect payment from Medicare, and any coinsurance and deductible from the patient. On an unassigned claim, you may also collect up to a 15% balance billing amount from the patient.

If Medicare denies payment You may collect full charges from the patient.

EMTALA (Emergency Medical Treatment and Active Labor Act) Designed to combat discriminatory practices of some hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of high costs associated with diagnosing and treating them.

EMTALA (Emergency Medical Treatment and Active Labor Act) Requires that Hospitals must provide appropriate medical screening exams (MSE) to anyone coming to the E.D. seeking medical care When the hospital determines that the patient has an emergency medical condition, the hospital must treat and stabilize the medical condition, or must transfer the patient A hospital must not transfer a patient with an emergency medical condition who has not been stabilized unless conditions are met that include effecting an appropriate transfer

EMTALA (Emergency Medical Treatment and Active Labor Act) If you see a patient in a setting and in circumstances to which EMTALA provisions apply, ASK, Has a Medical Screening Examination (MSE) by a qualified individual been completed?

No, the MSE is not complete. 1. Do not give an ABN 2. If you do not complete an MSE, no ABN may be given 1. Do not give an ABN. 2. First, complete an MSE. 3. Stabilize the patient. 4. Then give an ABN, but only if appropriate.

Yes, the MSE is complete. Is the patient stabilized? No.Yes. 1. Stabilize the patient.Give an ABN, but only if appropriate. 2. Give an ABN, but only if appropriate.

Do not routinely give ABNs to all emergency department patients who are Medicare beneficiaries. Even after a patient has received an MSE and is stabilized, do not give the patient an ABN unless you have a genuine reason to expect Medicare to deny payment for the services. Giving routine ABN notices is a prohibited practice.

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