# Hospital and ABN?



## MoonSad137 (Aug 29, 2012)

I work for a GI physician, who performed a colonoscopy at a local hospital in say March.  That colonoscopy was severely limited due to large amounts of retained stool, despite reaching the cecum the entire mucosa was not examined.  Medicare determined that the procedure was complete enough (apparently because the cecum was reached).  
About a month later the patient had a repeat procedure, this time however; the cecum was not reached due to retained stool limiting the examination, this time doctor was only able to reach the ascending colon because the stool was clogging the scope.

My office obtained an ABN from the patient for the second procedure and it appears the secondary (UHC) is processing the claim for payment.  

My concern is the bill the patient received from the hospital, a $4000 bill, since Medicare did not allow the second procedure (it does not appear that the hospital has adjusted the amount due to cash pay).  The hospital billing company states they've billed the secondary insurance who also disallowed the charges.  It does not appear the hospital obtained an ABN or anything of the sort.  When speaking with the hospital's billing it was determined that no modifier was used indicating reduced services on the second procedure or that an ABN was received.  I have assisted the patient in filing a dispute with the hospital regarding this.  Can they bill the patient without the ABN?  This is the first time (that I am aware of) that the hospital has done this to one of our patients.  

Any input is greatly appreciated! 

Thanks,
BH


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## MoonSad137 (Sep 6, 2012)

Does anyone have any input into this situation?


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## kevbshields (Sep 6, 2012)

What authority does the hospital have to bill the patient for this service, given that the charge was disallowed?  I'd encourage the patient to have a frank discussion over the lack of an ABN and see what the outcome is.  I am not aware of hospitals being exempt, primarily because they would also bill Medicare Part B.


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## mitchellde (Sep 7, 2012)

The physician office obtained the ABN and that is sufficient.  The patient agreed to the procedure and agreed to accept the charges.  The facility does not obtain a second ABN since the patient signed one already knowing the POS would be the facility.  The patient must work this out with the facility for the payment.   If the colonoscopy was considered complete the first time for the physician then it is complete for the facility as well which may be the reason they did not use a reduced modifier.


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## MoonSad137 (Sep 7, 2012)

mitchellde said:


> The physician office obtained the ABN and that is sufficient.  The patient agreed to the procedure and agreed to accept the charges.  The facility does not obtain a second ABN since the patient signed one already knowing the POS would be the facility.  The patient must work this out with the facility for the payment.   If the colonoscopy was considered complete the first time for the physician then it is complete for the facility as well which may be the reason they did not use a reduced modifier.



The ABN notifier is the physician only and only the physician estimated costs are given, since we do not bill for the hospital we have no way of knowing what their charges are.  I reviewed the instructions for ABN and it appears it is intended to be used as per provider, though it is not 100% clear.

The first procedure was deemed complete enough by medicare, that is not the claim with the problem.  The problem is with the second procedure which was clearly incomplete (physician billed as incomplete).  

Thanks for your input!  It's greatly appreciated.


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## kevbshields (Sep 7, 2012)

Correct.  What was estimated were the professional services alone.  Would the hospital even have a copy of this ABN?  I think not, but that is possible; regardless, that cost estimate is way off and that concerns me from a compliance standpoint.  My thought and hunch here is that the hospital did not do a thorough job of determining if a valid ABN was on file.  The staff may not have even known to look (yes, that is possible).  Therefore, it likely filed the claim to Medicare WITHOUT any ABN in the record or on file.  Don't you think that is troublesome?

If the patient is savvy to this, and disputes the charges with Medicare, I have read much material on this issue and the suggestion was that CMS contractors tend to side with the patient.


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## cocstudent1 (Sep 8, 2012)

*ABN issue*

In my experience, the patient should have brought the ABN with him to have the procedure done.  When patients come to the lab to have work done, they should bring the ABN with them when their lab work is done.  If I am billing/coding and there is a medical necessity edit that comes up I automatically look for an ABN, if I do not find one then I query for a medically necessary diagnosis. Oh and I work for a hospital.


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## kevbshields (Sep 9, 2012)

It is not the patient's responsibility to have the ABN, it is the health care provider's.


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## MoonSad137 (Sep 13, 2012)

Thank you all for your input!  I greatly appreciate it!


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