Medicare Compliance & Reimbursement

Denials shouldn't catch anyone off guard.

Just because a provider knows that not every procedure, service and test is a covered service doesn't mean that clients and patients are privy to the same information. It's the provider's job to inform the patient that he may wind up footing the bill.

That's where the advance beneficiary notice comes in. ABNs are a provider's best tool for informing clients of the services and procedures they may have to pay out-of-pocket for.

Problem: Constant Compliance Variances

But "the regulations and covered diagnoses change all the time," making the ABN process difficult for labs and physicians alike, says Jean Adler, a consultant with Adler Advisory Services in Los Angeles.

Solution: Providers should follow these rules to ensure their ABN compliance is up to snuff:

1. Use one ABN per event. "You cannot use a blanket ABN because some diagnoses are covered while others are not," Adler says. Also, providers should only use an ABN for non-covered services.

2. Be specific about why the service could be denied, advises Pat Zelenka, MT (ASCP), technical consultant with Avera Lab Network in Yankton, SD.
 
3. Give patients all their options if they choose not to have the procedure or test, experts say.

The bottom line: Providers should think of the ABN the same as any other contract, Zelenka suggests. 
  
Providers have to disclose all the information - even the deal-breakers - before it's too late for patients to make a different decision about treatment.