Medicare Compliance & Reimbursement

Experts: ABN will build patient trust.

Occasionally, a patient will present to the practice for an evaluation and management (E/M) service that Medicare might not pay for completely, if at all.

If you are unsure about whether Medicare will cover a patient’s E/M service, you should obtain an advance beneficiary notice (ABN) to keep compliant. Without an ABN on file, you could be on the hook for any part of the service Medicare doesn’t pay for.

Keep all your bases covered with these tips for handling ABN situations.

Green-Light ABN If Medicare Won’t Pay

According to experts, you should strive to get an ABN “anytime there’s suspicion that Medicare may not cover a procedure that they ordinarily would,” explains Leslie Johnson, CPC, CSFAC, chief coding officer at PRN Advisors in Palm Coast, Fla.

Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida, says you must issue an ABN when:

• You believe Medicare may not pay for an item or service;
• Medicare usually covers the item or service; and
• Medicare may not consider the item or service medically reasonable and necessary for this patient in this instance.

If you fail to obtain a signed ABN from the patient prior to rendering the service, your practice will not be able to collect any amount due from the patient when Medicare won’t cover for the service.

Extra tip: You might want to start getting proof of advanced patient notice for any service that a private payer might not cover, just to be safe. Some payers will accept the form Medicare created, others want you to use their form—some payers also may not allow you to bill their patients for services not covered. Checking with those payers about any ABN-type notice they’d like you to give to their patients is a good first step.

In short: Payers other than Medicare are now “requesting similar [ABNs] in writing. It’s a good habit for a practice to work into their routine, even if it seems difficult,” Johnson explains.

Medical Necessity, Service Frequency Could Spur ABN

ABN Can Help Patient Relations

Remember, if Medicare explicitly excludes a service by statute, it is not technically necessary to obtain an ABN. “However, in these situations, you may issue an ABN voluntarily,” Verno says.

Why? It will help with patient relations. Providing an ABN in any situation where the insurer might not pay “builds up the trust that the patient has with the provider. It shows a respect between the practice and the patient by stating what the cost will be, and giving the patient the choice as to whether they wish to proceed,” Johnson explains.

The patient might not like what they hear about a service being uncovered, but they’ll be a lot less happy if they get an unexpected Medicare bill. “By giving the patient this kind of respect, it places the provider and the practice in a win-win situation.” It also gives them a chance to decide if they want to proceed with the given service or treatment.