Home Health & Hospice Week

More than two years after it was proposed, Medicare's one-page advance beneficiary notice has become mandatory for home health agencies.

That means if HHAs fail to use the newly required form, they could have to furnish services for free to patients whose care they believe Medicare won't cover. And they could be found in violation of the conditions of participation as well.

Since the Office of Management and Budget approved the one-page ABN (CMS-R-296) in June 2002, agencies have been able to use either the new form or the old two-page ABN and still protect their ability to bill the patient if Medicare didn't cover services, and be in compliance with the COPs (see Eli's HCW, Vol. XI, No. 22, p. 174).

But now agencies must use the new form only, say new instructions in the Medicare Claims Processing Manual (Pub. 100-4). Medicare switched from using the HIM 11 manual to the new Internet-Only Manuals (IOMs) last fall (see Eli's HCW, Vol. XII, No. 33, p. 262).

When the Centers for Medicare & Medicaid Services first proposed the new ABN, there was much outcry from providers, recalls William Dombi, vice president for law with the National Association for Home Care and Hospice's Center for Health Care Law. Complaints about the form included: required demand billing for patients dually eligible for Medicare and Medicaid home care services; the requirement for agencies to write in a three-line blank the reason for Medicare's expected denial of services; and confusion on exactly when to issue the notice.

But HHAs appear to have settled into distribution of ABNs with few reported problems. "People have accepted the necessary nuisance" of furnishing the notices, Dombi says.

However, some of the reason agencies have reported few problems might be because they aren't issuing the notices as required by regulations, Dombi worries.

Agencies should follow these points from the manual instructions to ensure they are in compliance with ABN requirements, and thus protecting their COP status and their ability to bill patients for services denied by Medicare:

1. Issue ABNs for physician-ordered services only. If a physician agrees that Medicare won't cover services and changes her orders for home care, agencies don't have to issue a notice to the patient. HHAs must document the order change. But if a physician orders services an agency doesn't think Medicare will cover and she sticks by the order, the agency should furnish an ABN with an explanation of its reasoning to the patient.

2. Issue ABNs upon "triggering events" only. The manual defines triggering events as one of three changes to service: initiation, reduction or termination. Agencies also must re-issue ABNs once a year, as they expire, NAHC explains in ABN tips to its members.

3. Don't issue an ABN for routinely non-covered services. Agencies don't have to furnish a notice for services Medicare would never cover, such as custodial care.

4. Deliver ABNs on time. The notice won't be valid if the regional home health intermediary finds it to be delivered on too short of notice. "The HHA must notify the beneficiary well enough in advance before terminating or reducing home health services," the manual says. "'Well enough in advance' means the beneficiary has time to make other arrangements."

"Common sense must be applied to this criterion," the manual adds.

5. Obtain a receipt of delivery. "The patient or authorized representative must enter the date and signature on the appropriate line, keep the copy, and return the original to the agency," NAHC advises. The agency then must note the date of receipt on the original ABN, and return a copy to the patient within 30 calendar days.

"This may be done on the patient's copy at the time the HHABN is delivered and the patient or representative signs if delivered in person," NAHC says.

6. Make it readable. Agencies may customize only the "header" section of the form with their own identifying information. They can also add "information about the HHABN's implications for the beneficiary's other insurers" and other information "which is/are not explicitly required by these instructions," the manual says. HHAs can opt to make the notice legal size rather than letter size to accommodate additions.

If agencies use the Spanish version, the sections they fill in must also be in Spanish. In general, any blanks they fill in must be readable, the instructions say.

Editor's Note: The ABN instructions and links to the forms are in Chapter 30, Section 60.1 of the Claims Processing Manual at www.cms.hhs.gov/manuals/104_claims/clm104index.asp.