Home Health & Hospice Week

Reasons to give notices just multiplied.

Brace yourself to take on an even heavier paperwork burden by May 31.

After a long wait, the Centers for Medicare & Medicaid Services has issued the final, revised home health advance beneficiary notice (ABN). The agency issued new ABN forms and instructions last May in conjunction with the expedited review notices (see Eli's HCW, Vol. XIV, No. 18). But CMS failed to implement the new ABN when the expedited review notices went into effect last July 1.

Now revised ABNs are out and HHAs have until May 31 to switch to the new forms, CMS says.

As proposed, agencies will have to give out ABNs regardless of whether the physician agrees with the care changes. Currently, agencies issue ABNs only in the rare circumstances where physicians disagree with a change in care.

"HHAs must now issue HHABNs in a broader set of circumstances," CMS says in new instructions. "HHABNs will be issued more frequently."

"Agencies will be providing more HHABNs," warns Burtonsville, MD-based health care attorney Elizabeth Hogue. "The reasons for providing them have been significantly expanded."

The basics: Unlike under current requirements, agencies will have to issue ABNs for non-Medicare-covered care as well as covered care, CMS tells providers.

Agencies will issue the notices at three trigger points: (1) when initiating non-covered care, (2) when reducing non-covered or covered care, and (3) when terminating non-covered care.

Agencies don't have to issue ABNs when initiating or terminating covered care. Agencies must issue an expedited review notice instead when terminating covered care, CMS notes.

ABNs no longer just inform a patient of financial liability for non-covered services, CMS explains. Agencies will give notices when the beneficiary will not be charged, and when "there is no liability because non-covered charges are part of an otherwise covered bundled payment."

Steep Price For HHAs, No Benefit For Patients

The new ABN is "just too complicated and time consuming for no apparent real benefit," criticizes Bob Wardwell with the Visiting Nurse Associations of America. Even though agencies will be handing out tons more notices, CMS doesn't expect the increased number of ABNs to generate any additional appeals, CMS admits in its instructions.

"That pretty much says we are taking time away from care to give lots of new notices that will have no meaningful impact," fumes Wardwell, a former top CMS official.

The new notices will confuse patients and add costs to agencies already hit hard by the Medicare payment rate freeze, Wardwell protests. And the added paperwork burden will make retention of quality home care staff even harder, he predicts.

"Once again, Congress and CMS regulate to the worst case and burden ... the majority of HHAs to protect against the few bad actors," Wardwell laments.

And agencies still have to contend with the instructions' lack of clarity, Hogue says. "Reading the new instructions is ... going to be very discouraging."

The ABNs are inappropriate for home care in some instances, Hogue contends. For example, if an agency discharges a patient for being unsafe at home or abusive, it must issue an ABN that directs the patient to seek care from another HHA. The requirements "do not take into account the model of home care," she tells Eli.

ABNs Vs. Expedited Review Notices

Home health agencies have had lingering questions about when to issue an ABN versus an expedited review notice, notes Pat Conole with the Home Care Association of New York State.

Silver lining: CMS does finally spell out when to give each type of notice. HHAs must give both an ABN and an expedited review notice only when Medicare-covered care is ending (triggering the review notice) but non-covered care is continuing (triggering an ABN).

"The expedited notice gives information on the right to a quick decision from a [Quality Improvement Organization] affirming or disputing the end of all covered care," CMS explains. "The HHABN provides information on potential liability for care that would be delivered after coverage ends, and on claim-related appeal rights."

Agencies may be happy to see more ABN exceptions spelled out in the instructions, Wardwell adds. "There are some exceptions listed that take us off the hook for ABNs in situations where the most radical advocates would have insisted they be given."

And at least agencies will have a reasonable amount of time to adopt the new ABN forms and requirements, Wardwell notes. The deadline is May 31, CMS says in the ABN instructions. 

Note: The new ABN forms, including Spanish versions, and instructions are at www.cms.hhs.gov/BNI/03_HHABN.asp.