Home Health & Hospice Week

CMS offers up some differences between ABNs and termination notices.

Buckle up for a bumpy ride down the road to ABN compliance.
 
The Centers for Medicare & Medicaid Services issued the new advance beneficiary notice and its instructions in conjunction with a May 6 Federal Register notice (see Eli's HCW, Vol. XIV, No. 18, p. 140). With the new notice, home health agencies have a choice of including two different statements on the ABN.

The First Option

Under the first statement, agencies must estimate the cost of the services and items and say whether they think insurance will cover that cost. Then patients choose from these three options:
 
"1. I don't want the items and/or services listed above. I understand that I won't be billed for the items and/or services and that I have no appeal rights since I will not receive any items and/or services.
 
2. I want the items and/or services listed above, and I agree to pay for the items and/or services myself. I don't want a claim submitted to Medicare or any other insurance I have. I understand that I have no appeal rights since a claim won't be submitted to Medicare.
 
3. I want the items and/or services listed above and I want a claim submitted to (Please check one or both of the following):  _ Medicare  _ my other insurance."
 
The form then explains that if the patient selects option 3, she will receive a Medicare Summary Notice (MSN) detailing Medicare's official decision regarding whether Medicare will pay her claim. The MSN also will contain instructions on how to appeal that decision.
 
Good news: HHAs can charge upfront for the services in dispute. "You may have to pay the full cost at the time you get the items and/or services," the form warns. "If Medicare or your other insurance decides to pay for all or part of the items and/or services that you have already paid for, you should get a refund for the appropriate amount."
 
HHAs likely will issue the newly released termination notices for patients who want to appeal termination of services, notes consultant Regina McNamara with LW Consulting Home Health/Hospice Division in Harrisburg, PA. Then patients can pursue an expedited appeal and the agency's time of furnishing disputed services will be shorter. That's good because when "the care is not covered, the reality is that agencies will simply add to their uncollectible accounts," McNamara predicts.

The Second Option

Under the second statement, HHAs will issue this language to patients instead of the three options: "By signing below, I understand that the Home Health Agency's decision to no longer provide the items and/or services listed above doesn't change my Medicare coverage or other health insurance coverage. I also understand that I can't appeal the Home Health Agency's decision. However, I can try to get the items and/or services from another Home Health Agency. I may then try to get Medicare or any other insurance I have to cover the items and/or services."
 
This is the option agencies will use when they are discontinuing services for financial reasons such as staff shortages, says Chicago-based regulatory consultant Rebecca Friedman Zuber.

You May Issue ABNs and Termination Notices

"The new changes are ... far-reaching and potentially troubling and burdensome to agencies," McNamara warns. Because physicians' orders for the care at issue are no longer relevant, HHAs are bound to issue significantly more notices under the new rules if they want to stay in compliance, she says.
 
Even CMS admits the ABN burden will increase. The court decision that instigated the ABN changes, Lutwin v. Thompson, "significantly expanded situations where the notice is required in the home health setting," a CMS official tells Eli. But CMS can't quantify how much the issuances will increase, the staffer says.
 
Sometimes agencies will issue both ABNs and termination notices to one patient, the CMS official acknowledges.
 
HHAs will have to train staff on the new forms and their purposes, and staff will have to carry the forms with them all the time in case they find a patient to be non-homebound, McNamara expects.
 
This will be vexing for agencies that are trying to go to a completely paperless system, McNamara points out. "This new practice will add a task requiring paper, copying, storage, and filing - all elements they have been diligently attempting to phase out."
 
Pitfall: Agencies often will have difficulty furnishing ABNs in advance of terminating services, McNamara warns. HHA staff may suddenly find a patient isn't homebound, or the physician may abruptly discontinue home care after an office visit, she explains.

ABNs vs. Termination Notices

HHAs are scratching their heads trying to figure out exactly when they should use the ABN, the termination notice or both. CMS will issue educational materials that will help agencies figure out when to use which form, the official promises - but those materials aren't scheduled to come out soon.
 
Until then, here are some differences between the two notices, the CMS staffer explains to Eli: