Medicare Compliance & Reimbursement

When Medicare is shy, break the ice with these forms.

Misinterpreting the extensive rules for advance beneficiary notices (ABNs) saddles many providers with needless bills and compliance problems. But following a few simple guidelines will keep them in the know about when they need a patient's John Hancock and when they don't.

1. Specify the Reason

What service does the provider think Medicare will deny, and more important, why do they think Medicare won't pay? Include this information on the ABN, and in language the patient can understand. Just saying the service is "medically unnecessary" isn't enough, said Thomas Bartrum, attorney at Baker Donelson Bearman & Caldwell in Nashville, TN, at the American Health Lawyers Association's Institute on Medicare and Medicaid Payment Issues.

Providers should list details about why they think Medicare will deny the service, and document multiple reasons if they're relevant. Without the highest possible specificity in the explanation, Medicare may consider the notice "routine," a faux pas that invites trouble from CMS' Routine Notice Prohibition and may leave the provider with liability.

2. Use the Proper Form

As of Jan. 1, 2003, form ABN-G, provided by CMS, should grace the hands of all patients for whom providers expect Medicare denials. Providers need one copy to hold on to, and one copy for the patient -- and they must be exactly the same, Bartrum says, because if one copy gets altered or the beneficiary doesn't have one, and the patient complains of the inconsistency, fiscal intermediaries (FIs) will side with her, not the provider.

While ABN-G is a standardized form, providers do have limited leeway to tailor it to their needs. Three areas are open to customization: the header, the "Items or Services" box, and the "Because" box. Providers should not let the whole form exceed one page, but if they really need the space, it's OK to cheat by printing it on legal-size paper to increase the amount of customizable room.

3. Ease the Patient's Pressure

Using the information provided on an ABN, the patient can make a better-informed decision about whether he wants the physician to perform the procedure, says Kathryn Cianciolo a coding consultant in Waukesha, WI. This information is all the more crucial given that the patient will probably have to pay for the procedure, she says.

Cianciolo recommends obtaining an ABN anytime a diagnostic procedure doesn't match up with the proper diagnosis code, or anytime the provider is uncertain whether Medicare will reimburse for the procedure.

CMS says providers need to get the patient an ABN as soon as they suspect Medicare won't pay, but in realistic terms, Bartrum says, that means providing it before the providers furnish the service. The patient shouldn't be under pressure to decide beyond the stress inherent in the current medical situation. Allowing him to make a rational, informed choice means delivering the ABN not only before the procedure but also before the patient is given any physical preparation for it. His presence in the room of service -- an exam room, for instance -- doesn't count as "physical preparation," so doing the paperwork then is not creating a pressure situation.

Most of the time providers can supply the form by hand, but when that's impractical or impossible, other routes are legit, such as mail, fax or online notice. Providers can also notify the beneficiary by phone, but they should certify their call with a mailed form or a personal visit with a form in hand.
 
4. Deliver Despite Rain, Sleet, Snow or Hail

Though delivering the ABN to the beneficiary is often as simple as handing him a piece of paper and getting it back with a signature, the CMS "delivery" requirement harbors a sometimes slippery detail: The patient must be able to understand the form. A host of patient impairments can frustrate comprehension of the ABN, including legal incompetence, illiteracy, blindness, inability to understand English or Spanish, or confusion due to dementia or Alzheimer's, even simply excessive duress.

Just because one of these stumbling blocks is in the way doesn't mean providers are off the hook, Bartrum says. Providers are responsible for navigation around the obstacle, whether that means contacting an authorized beneficiary or providing a notice in Braille.