Home Health & Hospice Week

Don’t let an ABN change sneak past you. While the Centers for Medicare & Medicaid Services isn’t revamping the Advance Beneficiary Notice itself, it is proposing a change to the ABN instructions, notes the National Association for Home Care & Hospice.

“Guidelines for Dual Eligible beneficiaries have been added to the ABN form instructions,” CMS says in its Paperwork Reduction Act documents supporting the change. “Dually Eligible benefi­ciaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication,” CMS instructs. But you should strike through the language that says “You may ask to be paid now” and “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.”

Why? “These edits are required because the provider cannot bill the dual eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries,” the PRA document explains.

“If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudi­cation based on State Medicaid coverage and payment policy,” CMS continues. “Medicaid will issue a Remittance Advice based on this determination.”

The instructions then explain that once the claim is adjudicated by both Medicare and Medicaid, providers may charge the patient only when the beneficiary has QMB coverage without full Medicaid coverage, or when the beneficiary with full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid).

Plus: “These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances,” CMS adds.

You can submit comments on this change until Oct. 21. Commenting instructions and a link to the supporting PRA materials are in the rule at www.govinfo.gov/content/pkg/FR-2019-08-20/pdf/2019-17945.pdf.