Leading with Compliance: The Advanced Beneficiary Notice (ABN) Form

Agenda What is the ABN Form? What does it do? Who is it for? Why do you need to fill out the form? How do you fill out the form?

What is the ABN Form? The Advanced Beneficiary Notice (ABN) is documentation that assures Medicare patients have been fully informed of their responsibility to pay for tests ordered but not routinely reimbursed by Medicare. It is a legal requirement for people enrolled in original, fee-for-service Medicare.

What does the ABN do? The ABN enables the beneficiary to make an informed decision about whether to order services and accept financial responsibility for those services if Medicare does not pay. The ABN serves as proof that the beneficiary knew prior to getting the service that Medicare might not pay. If you do not issue a valid ABN to the beneficiary when Medicare requires, you cannot bill the beneficiary for the service and you may be financially liable.

Who is the form for? The ABN is for Medicare patients only. The Advance Beneficiary Notice (ABN) is only administered to MEDICARE beneficiaries. It is a written notice that the Ordering Physician or healthcare provider gives to a Medicare Beneficiary.

The ABN is required for the following tests: CYP2D6 – metabolizes 25% of all drugs including tamoxifen, many antidepressants, antipsychotics, betablockers and opioids CYP2C9 – metabolizes approximately 10% of all drugs including warfarin, phenytoin, non-steroidal anti-inflammatory drugs (NSAIDs), and sulfonylureas

Why do you need to fill out the form? A properly executed ABN is required to allow PGXL Laboratories to bill the patient. The ABN must be signed before the sample is collected.

How to fill out the form Use the most current version of The Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131(03/11) Complete the ABN in pen by providing the required information in the spaces provided on the form. a. Patient’s full name as it appears on his or her Medicare Card b. Medicare Number (HICN number) c. Complete the reason you expect Medicare to deny the claim by writing the test name in the appropriate column i. Medical Necessity ii. Frequency Limitations iii. Experimental or research test d. Estimate the laboratory cost using the PGXL LIST fee schedule e. Allow the patient to select one of the following options

OPTION 1: I want the D. (name of test) listed above OPTION 1: I want the D. (name of test) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

OPTION 2: I want the D. (name of test) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3: I don't want the D. (name of test) listed above OPTION 3: I don't want the D. (name of test) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

PGXL Laboratories will not report or bill any test in the above list that does not have a fully correct and executed ABN.

Patient Responsibility PGXL will send the patient two bills. PGXL expects the patient to pay the balance that is due for the testing provided. The price list for each test is on www.pgxlab.com/abn.

The ABN policy will take full effect as of October 1, 2013 The ABN policy will take full effect as of October 1, 2013. PGXL will use the next 45 days, to notify EM of instances that fall short of the policy, so the field is ready for the go-live date.

Coming up: New requisition form details

Visit www.pgxlab.com/abn