The advance beneficiary notice (ABN) is a powerful tool for practices to educate patients about their benefits and responsibilities for Medicare non-covered services. Many of our readers still write us to ask questions about the form and the correct way to use it in the office, so we developed this Frequently Asked Questions list for the ABN to clear up some of the confusion.
We always tell the physicians we work with: “If you are going to accept insurance, you need to be the expert on insurance.” In practice this means knowing your patient’s benefits and working with them to communicate with them about what, if anything, they will owe before or after payer adjudication. No one enjoys being surprised about money!
The ABN is also a tremendous opportunity to talk about financial responsibilitieswith a patient. If you don’t have a credit card on file program in your practice, it’s important to be proactive about patient financial responsibilities and how they will be handled. Having a patient sign that they understand they will be financially responsible for payment for a non-covered service is a natural way to start that process.
Here are some of your most frequently asked ABN questions.
What is the ABN? What does it do?
The ABN was originally developed by the Centers for Medicare and Medicaid Services (CMS) to make sure Medicare patients were aware that if they received services that were not covered by Medicare, payment for these services would be their responsibility. By signing the ABN, the patient agrees that if Medicare (or other payer) does not pay the physician then the patient will have to pay for it. The document affirms that the patient knows they could be required to pay out of pocket. Once the ABN is signed, if you are sure Medicare won’t pay you can (and probably should) collect the patient portion listed on the form immediately. You can charge in full for the services if the ABN is signed, however the service is self-pay at that point, so I always suggest you charge your self-pay rate.
What won’t Medicare pay for?
The classic example is an annual physical, which many people assume is part of their Medicare coverage. Medicare will pay for an initial “Welcome to Medicare” visit, as well as an “Annual Wellness” visit, but the key word to hear is “visit”. These are not physical examinations. If a patient wants a physical, they will need to sign an ABN before the service saying they understand that Medicare will not pay for it. Other things that Medicare will not pay for include services without specific medical need, like labs or imaging diagnostics without diagnoses that are accepted as medically necessary. Medicare will also only pay for certain services at regular intervals, for example women who are considered “low risk” for cervical cancer can only receive a pap smear every 24 months. Note that you are not required by Medicare to get an ABN signed for services that are never covered, such as the annual physical, however, it pays to be absolutely clear when discussing payments, so I suggest you get an ABN signed by the patient regardless.
Should we just have everybody sign an ABN?
No. The ABN is to be used in specific instances for a specific service. You cannot require a patient to sign a “blanket” ABN for the year, just in case. If Mr. Smith wants a service that Medicare is unlikely to, or definitely will not pay for and the physician is comfortable ordering or performing the service, a staff member should present an ABN to Mr. Smith for that specific day’s procedure, before it is performed. If the patient is a having a series of recurring services that will not be covered, you can have one ABN signed for up to twelve months of the specific service. An example of this might be a series of physical therapy sessions. The ABN is not a catch- all to protect from denial, however, and persistent misuse will not only be denied, but could open the door to an audit.
We are a small, busy practice; that sounds like a lot of work!
It is a lot of work for a practice! Many practices choose to not use the ABN rather then work out a protocol to implement it. The practice has to have a system in place so that the physician or staff member can explain the situation, fill out the form, answer the patient’s questions and file the ABN for posterity (they have to be kept seven years, like other records). It can be the physician in a micropractice, or a dedicated billing or customer service employee in a larger setting. Also, a note has to be made of the ABN signing in the patient’s chart so that modifiers can be added to the CPT codes for billing.
Are ABNs for Medicare only?
No. You can also have a patient sign an ABN for a private payer. This helps the patient to understand that if their insurance doesn’t cover the service specified, the patient will have to pay for it. Medicare requires an ABN be signed in order to bill the patient, but for patients with private insurance it’s still a great opportunity to talk about non-covered services, deductibles, copays, coinsurance or any past balances if you haven’t already. A few private payers actually require a waiver/ABN to bill patients for non-covered services – check your contract to be sure.
Mary Pat has created a generic non-Medicare ABN; if you’d like a copy for $20, just email Mary Pat and she can send you one.
The extensive changes coming for Medicare Part B coverage in 2011 should have primary care practices and some specialty practices thinking about their current processes. If you meet with your team now to educate them about the Medicare changes and explore process tweaking, you’ll be ready when January 1 rolls around.
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Here are a few areas to think about:
Advance Beneficiary Notices (ABNs) – Many practices struggle with the who and when of ABNs and the new coverage might not make it easier. There are lots of services now covered with new frequency limitations, so practices must be on their toes to recognize when a service is covered and when it isn’t. Sure, you can ignore ABNs and wait for Medicare to tell you a service is not covered, but then it’s too late to collect from the patient – not only too late, but also illegal to collect.
The annual wellness visit is going to be a special challenge because the timing is precise. Medicare patients will hear “annual visit”, but won’t realize it will not be paid for if performed within 12 months of a previous wellness visit (Welcome to Medicare exam or annual visit). I’ve not seen any practice management software that handles this really well, but maybe it’s out there. I’d love to see Medicare patients scheduling their annual visits during their birthday month so staff would have a fighting chance of identifying the last annual visit and getting the date right. Of course, using your electronic recall will work too if you schedule the next year’s visit when the patient is checking out. (Do you proactively contact your Medicare patients to invite them to come in for their Welcome to Medicare exam?)Also encouragepatients to keep up with the preventive services they are eligible to receive by registering with the My Medicare website (https://mymedicare.gov/). This is their personal Medicare website for tracking their Medicare services. It will send them e-mail reminders when they are eligible for Medicare coverage of preventive services. Great idea!
Who will be doing the counseling about the “preventive services covered by Medicare” during the annual exam? Let’s hope Medicare puts out a really great handout!
Most EMRs will let you load requirements for services based on diagnosis – for example, diabetes. Make sure you are taking advantage of the EMR’s ability to set up protocols for age, diagnosis and risk factors.If you are not on EMR yet, use your appointment schedule or recall system to set reminder appointments to contact patients for their services.
Don’t forget your patients on Medicare who are not yet age 65. Run a report to find these patients and flag them to acknowledge that their Medicare services are at different times.
Collections at time of service will change too, of course, as most services listed below will not be applied to the deductible. Exceptions are glaucoma screening, diabetes monitoring and education, medical nutritional, and smoking cessation. Patients understandably will be confused, so make sure your check-out staff are crystal clear.
Medicare Benefits Beginning January 1, 2011
Medicare covers a one-time preventive physical exam within the first twelve months of having Part B. The exam will include a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if needed. No Part B deductible and effective January 1, 2011 you pay nothing if the doctor accepts assignment.
Abdominal Aortic Aneurysm Screening – People at risk for abdominal aortic aneurysms may get a referral for a one-time screening ultrasound at their “Welcome to Medicare” physical exam. Effective January 1, 2011 no deductible and no copayment.
New Annual Wellness Visit – Effective January 1, 2011 Medicare will cover an Annual Wellness Visit that includes a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if you need it. It is available every 12 months (after first 12 months of Part B coverage) but not within 12 months of receiving either a “Welcome to Medicare” physical exam or another Annual Wellness Visit. No Part B deductible ”“ Medicare pays 100% of the approved amount.
Cardiovascular Screening Blood Tests – Medicare covers cardiovascular screening tests that check cholesterol and other blood fat (lipid) levels every 5 years. Includes:
Total Cholesterol Test
Cholesterol Test for High Density Lipoproteins; and
No Part B deductible ”“ Medicare pays 100% of approved amount.
Diabetes Screening Tests – Anyone enrolled in Medicare identified as “high risk” for diabetes will be able to receive screening tests to detect diabetes early. Covers up to two screenings each year. Includes:
Fasting plasma glucose test
Post-glucose challenge test
No Part B deductible ”“ Medicare pays 100% of approved amount
Glaucoma Screening – Must be done or supervised by an eye doctor (optometrist or ophthalmologist). Covered annually for:
Those with diabetes
Those with a family history of glaucoma
African-Americans age 50 and older
Hispanic-Americans age 65 and older
Other high risk individuals
Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
Bone Mass Measurement – For those enrolled in Medicare at high risk for losing bone mass. Effective January 1, 2011 no Part B deductible ”“ Medicare pays 100% of approved amount.
Screening Mammography (including new digital technologies) – For women age 40 and older enrolled in Medicare:
No Part B deductible ”“ Medicare pays 100% of approved amount beginning January 1, 2011.
Screening Pap Test & Pelvic Examination (Includes clinical breast examination) – For all women enrolled in Medicare:
Covered once every two years for most
Covered annually for women at high risk
No Part B deductible ”“ Medicare pays 100% of approved amount for Pap test and effective January 1, 2011 pays 100% of approved amount for pelvic and breast exam.
Colorectal Cancer Screening – For all those enrolled in Medicare age 50 and older:
Fecal-Occult blood test covered annually ”“ No Part B deductible & Medicare pays 100% of approved amount.
Flexible sigmoidoscopy once every four years or 10 years after a previous screening colonoscopy”“ No Part B deductible or copayment starting January 1, 2011.
Barium enema can be substituted for sigmoidoscopy or colonoscopy ”“ No Part B deductible – Medicare pays 80% of the approved amount. You will pay a higher coinsurance if the test is done in a hospital outpatient department.
Colonoscopy for any age enrolled in Medicare
Average risk – Once every ten years, but not within four years after a screening flexible sigmoidoscopy
High-risk – Once every two years
No Part B deductible and effective January 1, 2011 Medicare pays 100%.
Prostate Cancer Screening Tests -For all men enrolled in Medicare age 50 and older:
Digital rectal exam ”“ Medicare pays 80% of the approved amount after the deductible
Prostate Specific Antigen (PSA) test
No Part B deductible – Medicare pays 100% of approved amount.
Diabetes Monitoring and Education – Covers Type I and Type II diabetics enrolled in Medicare who must monitor blood sugar (Not paid for those in a nursing home) Covered services:
Glucose-monitoring devices, lancets & strips
Education & training to help control diabetes
Foot care once every 6 months for those with peripheral neuropathy
Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
Medical Nutritional Therapy – Covered for those with diabetes or kidney disease. Includes diagnosis of special nutrition needs, therapy and counseling services to help you manage your disease. Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
Smoking Cessation Services – Medicare will cover up to 8 counseling sessions per year for individuals who have an illness caused or complicated by tobacco use or you take medication affected by tobacco use. Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
Flu Vaccination Annually (Medicare pays once per season. You do not have to wait 365 days since your last one.) No Part B deductible ”“ you pay nothing if your doctor accepts assignment. My post on billing for the flu shot is here.
H1N1 Flu Vaccine Medicare covers the administration of the H1N1 flu shot. You cannot be charged for the vaccine. No Part B deductible or co-insurance.
Pneumococcal Pneumonia Vaccination– Once per lifetime for all enrolled in Medicare. (A doctor may order additional ones for those with certain health problems.) No Part B deductible ”“ Medicare pays 100% of approved amount.
Hepatitis B Shots – Covered for those who are at medium or high risk. Effective January 1, 2011, there will be no Part B deductible and Medicare pays 100%.
The Office of the Inspector General just unveiled their 2011 Work Plan in a remarkably readable and succinct 159 pages. The Work Plan reveals their review targets for the coming year. The entire plan ishere, but I’ve excerpted the parts that I thought would be of most interest to MMP readers. Skip to the bottom to get to my top ten pointers for physician practices for 2011.
Medicare Secondary Payer/Other Insurance Coverage
We will review Medicare payments for beneficiaries who have other insurance. Pursuant to The Social Security Act, § 1862(b), Medicare payments for such beneficiaries are required to be secondary to certain types of insurance coverage. We will assess the effectiveness of procedures in preventing inappropriate Medicare payments for beneficiaries with other insurance coverage. For example, we will evaluate procedures for identifying and resolving credit balance situations, which occur when payments from Medicare and other insurers exceed the providers’ charges or the allowed amounts.
(OAS; W”00”11”35317; various reviews; expected issue date: FY 2011; new start)
Medicare Brachytherapy Reimbursement
We will review payments for brachytherapy, a form of radiotherapy where a radiation source is placed inside or next to the area requiring treatment, to determine whether the payments are in compliance with Medicare requirements. Pursuant to the Social Security Act, § 1833 (t)(16)(C), as amended by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), § 142, Medicare pays for radioactive source devices used in treatment of certain forms of cancer.
(OAS; W”00”10”35520; W”00”11”35520; various reviews; expected issue date: FY 2011; work in progress)
We will review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers (ASC) and hospital outpatient departments. Federal regulations at 42 CFR § 414.32 provide for different levels of payments to physicians depending on where the services are performed. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC. We will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments.
(OAS; W”00”09”35113; W”00”10”35113; various reviews; expected issue date: FY 2011; work in progress)
Coding of Evaluation and Management Services
We will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments. Pursuant to CMS’s Medicare Claims Processing Manual, Pub. No. 100”04, ch. 12, § 30.6.1, providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. We will review E&M claims to determine whether coding patterns vary by provider characteristics.
(OEI; 04”10”00180; expected issue date: FY 2011; work in progress)
Payments for Evaluation and Management Services
We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS’s Medicare Claims Processing Manual, Pub. No. 100”04, ch. 12, § 30.6.1 instructs providers to “select the code for the service based upon the content of the service” and says that “documentation should support the level of service reported.” Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.
(OEI; 04”10”00181; 04”10”00182; expected issue date: FY 2012; work in progress)
Evaluation and Management Services During Global Surgery Periods
We will review industry practices related to the number of E&M services provided by physicians and reimbursed as part of the global surgery fee. CMS’s Medicare Claims Processing Manual, Pub. No. 100”04, ch. 12, § 40, contains the criteria for the global surgery policy. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period. We will determine whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.
(OAS; W”00”09”35207; various reviews; expected issue date: FY 2011; work in progress)
Medicare Payments for Part B Imaging Services
We will review Medicare payments for Part B imaging services. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expense. The Social Security Act, § 1848(c)(1)(B), defines “practice expense” as the portion of the resources used in furnishing the service that reflects the general categories of expenses, such as office rent, wages of personnel, and equipment. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. We will determine whether Medicare payments reflect the expenses incurred and whether the utilization rates reflect industry practices.
(OAS; W”00”11”35219; various reviews; expected issue date: FY 2011; new start)
Appropriateness of Medicare Payments for Polysomnography
We will review the appropriateness of Medicare payments for sleep studies. Sleep studies are reimbursable for patients who have symptoms consistent with sleep apnea, narcolepsy, impotence, or parasomnia in accordance with the CMS Medicare Benefit Policy Manual, Pub. No. 102, ch. 15, § 70. Medicare payments for polysomnography increased from $62 million in 2001 to $235 million in 2009, and coverage was also recently expanded. We will also examine the factors contributing to the rise in Medicare payments for sleep studies and assess provider compliance with Federal program requirements.
(OEI; 00”00”00000; expected issue date: FY 2012; new start)
Medicare Payments for Sleep Testing
We will review the appropriateness of Medicare payments for sleep test procedures provided at sleep disorder clinics. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” CMS’s Medicare Benefit Policy Manual, Pub. No. 100”02, ch. 15, § 70, provides CMS’s requirements for coverage of sleep tests under Part B. A preliminary OIG review identified improper payments when certain modifiers are not reported with sleep test procedures. We will examine Medicare payments to physicians and independent diagnostic testing facilities for sleep test procedures to determine whether they were in accordance with Medicare requirements.
(OAS; W”00”10”35521; W”00”11”35521; various reviews; expected issue date: FY 2011; work in progress)
Excessive Payments for Diagnostic Tests
We will review Medicare payments for high”cost diagnostic tests to determine whether they were medically necessary. The Social Security Act, § 1862 (a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” We will determine the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.
(OAS; W”00”11”35454; various reviews; expected issue date: FY 2011; new start)
Medicare Part B Payments for Glycated Hemoglobin A1C Tests
We will review Medicare contractors’ procedures for screening the frequency of clinical laboratory claims for glycated hemoglobin A1C tests. CMS’s Medicare National Coverage Determinations Manual, Pub. 100”03, Ch. 1, pt. 3, § 190.21, states that it is not considered reasonable and necessary to perform a glycated hemoglobin test more often than every 3 months on a controlled diabetic patient unless documentation supports the medical necessity of testing in excess of national coverage determinations guidelines. Preliminary OIG work at two Medicare contractors showed variations in the contractors’ procedures for screening the frequency of glycated hemoglobin A1C tests. We will determine the appropriateness of Medicare payments for glycated hemoglobin A1C tests.
(OAS; W”00”11”35455; various reviews; expected issue date: FY 2011; new start)
Independent Diagnostic Testing Facilities’ Compliance With Medicare Standards
We will review selected IDTFs enrolled in Medicare to determine the extent to which they comply with selected Medicare standards. IDTFs received payments of about $860 million in 2009. Federal regulations at 42 CFR § 410.33, require IDTFs to certify on their enrollment applications that they comply with 17 standards. Such standards include requirements that IDTFs comply with all of the Federal and State licensure and regulatory requirements that are applicable to the health and safety of patients, provide complete and accurate information on their enrollment applications, and have on duty technical staff members who hold appropriate credentials to perform tests. We will also identify billing patterns associated with IDTFs that were not compliant with selected Medicare standards.
(OEI; 05”09”00560; expected issue date: FY 2011; work in progress)
Image by ciotka via Flickr
Medicare Providers’ Compliance With Assignment Rules
We will review the extent to which providers comply with assignment rules and determine whether and to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare requirements. Pursuant to the Social Security Act, § 1842(h)(1), physicians participating in Medicare agree to accept payment on an “assignment” for all items and services furnished to individuals enrolled in Medicare. CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician or other supplier in return agrees to accept the Medicare”allowed amount indicated by the carrier as the full charge for the items or services provided. We will also assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines.
(OEI; 00”00”00000; expected issue date: FY 2012; new start)
Medicare Payments for Claims Deemed Not Reasonable and Necessary
We will review Medicare payments for Part B claims in 2009 that providers note as not reasonable and necessary on claim submissions. The CMS Claims Processing Manual states that providers may use GA or GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary. A recent OIG study found that Medicare paid for 72 percent of pressure”reducing support surface claims with GA or GZ modifiers, amounting to $4 million in potentially inappropriate payments. We will determine the extent to which Medicare paid for Part B claims with these modifiers, as well as the types of providers and the types of services
associated with these claims. We will also assess the policies and practices that Medicare contractors have in place with regard to these claims.
(OEI; 02”10”00160; expected issue date: FY 2011; work in progress)
Medicare Billings With Modifier GY
We will review the appropriateness of providers’ use of modifier GY on claims for services that are not covered by Medicare. CMS’s Medicare Carriers Manual, Pub. No. 14”3, pt. 3, § 4508.1, states that modifier GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service. Beneficiaries are liable, either personally or through other insurance, for all charges associated with the provision of these services. Pursuant to CMS’s Medicare Claims Processing Manual, Pub. No. 100”04, ch. 1, § 60.1.1, providers are not required to give beneficiaries advance notice of charges for services that are excluded from Medicare by statute. As a result, beneficiaries may unknowingly acquire large medical bills for which they are responsible. In FY 2008, Medicare received over 75.1 million claims with a modifier GY totaling approximately $820 million. We will examine patterns and trends for physicians’ and suppliers’ use of modifier GY.
(OEI; 00”00”00000; expected issue date: FY 2012; new start)
To Re-Cap, here’s YOUR Work Plan for 2011:
If you’re not using the MSP questionnaire in your practice for Medicare patients, start. Here’s a fact sheet (pdf) to get up to speed.
If your practice provides brachytherapy, ensure that you are following the MIPPA guidelines for diagnoses.
Check your place of service codes and make sure they are absolutely correct on all counts.
Don’t wait for Medicare to audit your documentation, audit it yourself or hire a professional to audit for you. Make sure the coding is correct for what was documented. If you are using an EMR, beware of over-dependence on templates! If your practice performs surgery, track that global period like a hawk and make sure you understand when you may or may not bill an E & M code during the global period.
Sleep studies – if you do them, make sure the diagnosis and medical necessity support them.
Does your practice provide imaging services? Are your utilization rates above the national average for your specialty? Was the service medically necessary? It’s a good time to find out. Oh, and don’t forget to disclose any financial interest your practice has in any imaging center and to provide the patient options for other centers.
Hemoglobin A1c – first we weren’t doing enough, now we’re doing too many! Medicare will pay for a hemoglobin A1c every three months for diabetic patients. Make sure to have an electronic or manual system in place for tracking this. Most practices use a diabetic flow sheet in a paper chart – start using one if you aren’t now.
Do you have an IDTF? Do you comply with the 17 standards you certified upon enrollment?
Are you “par” (participating) or “non-par” (non-participating) with Medicare? Are you collecting the appropriate amount from Medicare patients?
My favorite – the ABN – Advanced Beneficiary Notice. Are you using the ABN correctly and advising Medicare patients of their rights? Or are you just telling them to “Sign here, please”? Here’s an article about ABNs published on MMP.
Will you be called to task in 2011 for the above 10 items?
There is tremendous pressure on Medicare and other government-sponsored payers to weed out fraud and eliminate waste. It is the responsibility of the professional administrator to protect the practice from risk, as well as guide the office in all things legal and ethical. You may be the only one in your practice who understands the liability that non-compliance can expose the practice to – make sure your practice does it right!