Inpatient Facility Coding & Compliance Alert

Question: The practice I am associated with seems to ask patients for ABNs quite frequently. Do we have any guideline we need to be aware of regarding the number of patients signing ABNs in a given time period? 

Tennessee Subscriber

Answer: If you’re dealing with a Medicare patient, you should use an advance beneficiary notice (ABN), a written notice a provider gives a Medicare beneficiary, only before furnishing items or services you believe Medicare will not pay for on the basis of medical necessity.

Commercial payers do not always require you to use an ABN to allow the provider to collect from the patient for non-covered or non-medically necessary services, but you should check to be sure which rules your commercial insurers apply.

Medicare doesn’t allow “blanket” use of ABNs (giving an ABN to every Medicare patient), but you can give an ABN to every patient who is having a frequency-limited service, such as those allowed once a year. CMS permits this because your practice has no way of knowing for sure when the patient had her last exam.

Have the patient sign the ABN, then give her a copy, and keep the original in your files. This way you know — and can prove — you put the patient on notice that Medicare coverage is unlikely. With this information, the patient is then in a better position as a healthcare consumer to make an informed decision regarding the services.

Plus: When issuing an ABN, you must advise a pediatric patient’s parent that she will be personally and fully responsible for payment of all items and services specified on the ABN if Medicare denies the claim. ABNs, at least for Medicare, require specific information concerning the test (service), the charges that the Medicare beneficiary agrees to pay, etc.

Be aware that Medicare considers an ABN improperly issued under the following circumstances:

• When the provider refuses to answer inquiries from a patient or the patient's authorized representative.
• When a practice uses an ABN to shift liability to the beneficiary for items/services when other payments are considered to include full payment for those items/services.