Medicare Compliance & Reimbursement

You still have to issue an ABN if the reduction is included in the recent plan of care.

Get ready to crank out even more home health advance beneficiary notices than you expected come June 1.

The Centers for Medicare & Medicaid Services has issued 25 new questions and answers on the troublesome subject of ABNs, and home health agencies aren't happy with many of the new clarifications.

"The HHABN regulations are unbelievably complex and absolutely overboard," blasts Lynda Laff, chief operating officer with Island Health Care based in Savannah, GA.

ABN rules are "horribly complicated," criticizes Chicago-based regulatory consultant Rebecca Friedman Zuber. Instead of facilitating a dialog between HHAs and patients, the new ABN "clutters up communication."

"CMS has told us to flood the beneficiaries with notices and we just have to figure out the most efficient way to do so," laments Bob Wardwell with the Visiting Nurse Associations of America.

Warning: "Creating a level of notice requirements that is this overwhelming invites non-compliance," adds Wardwell, a former top CMS official.

Recert ABN Workload Increases

One big surprise for many HHAs: CMS' direction to issue ABNs for service reductions that are included on the plans of care for subsequent recertification episodes. "If reductions occur at the time of recertification, the HHA should convey that information with an HHABN," CMS instructs in Q&A #10.

Even if the reductions happen after the recert episode begins, agencies still must issue an ABN at some point. "If reductions are expected on the plan of care over the next 60 days, the HHA can choose to convey that information to the beneficiary using an HHABN at the time of recertification," CMS explains. "In this case, no further HHABN would be needed when those reductions occurred as anticipated."

In other words, if services continue as usual for a week or two into the second episode, then drop as outlined in the recert plan of care, agencies have two options, explains attorney Robert Markette Jr. with Gilliland Markette & Milligan in Indianapolis. Option one is to issue the ABN at recert time. Option two is to issue the ABN when the service reduction actually takes place.

Take heed: But no matter what, the agency must issue an ABN for a service reduction, even if it is on the recert plan of care, Markette emphasizes. Only service reductions included on the original, first episode POC are exempt from ABNs, he advises.

"This is a new twist that many may not have interpreted with the original instructions," judges consultant Judy Adams with Charlotte, NC-based Larson-Allen. "With this clarification, even when there are written MD orders in advance of reducing the services for a new episode, the agency will have to do an HHABN."

It's "ridiculous" to issue an ABN when services are reduced at recert, Zuber protests. "Everyone understands there is a new plan of care after a 60-day episode; why do we need the ABN?" she asks.

And HHAs typically do reduce services in the second episode, Laff notes. That means they'll be issuing a lot more ABNs based on this guidance.

Do this: Because issuing a recert ABN is a departure from past notice requirements, agencies will need to educate clinicians about this new instance of needing to issue the ABN, advises Laura Gramenelles with Simione Consultants in Westborough, MA.
 
Other issues addressed in the Q&As include:

• Other payors. CMS actually reverses previous guidance and gives providers a slight break in one area of ABN issuances. When patients' coverage switches from Medicare to another payor, such as Medicaid, agencies no longer need to issue an ABN, CMS explains in Q&As #14 through #16.

"Only one HHABN would be given at the beginning of Medicare noncovered care, unless the beneficiary again became eligible for Medicare coverage and a triggering event occurred," CMS explains. The agency will add the clarifications to the final ABN instructions, it says.

This change is "some sliver of hope" in an otherwise crushing new burden, Markette notes. The change provides "minimal relief," Adams agrees.

Watch out: But agencies will need to track carefully when their patients move from Medicare to other insurers to make sure they're staying in compliance with ABN rules, Gramenelles cautions.

And CMS makes clear that if the patient herself takes over payment instead of another payor after Medicare coverage ends, agencies are still on the hook to issue ABNs. "The point to remember is that if there is no other payor, the patient will need to receive an HHABN at every triggering event--reduction and termination," Gramenelles counsels.

• Non-Medicare-covered services. Agencies may be surprised to see that CMS is requiring them to include non-Medicare-covered services, such as telehealth and nutrition services, in the ABN rules. "You need to give the HHABN, assuming that these services are integrated with Medicare-covered care that is also being delivered, or care is being provided to a Medicare beneficiary with no other insurance," CMS directs in Q&A #19.

"Reductions and terminations of integrated services such as telemonitoring should continue to be handled with physician orders," Laff protests. "I cannot imagine having to issue ABNs for this."

HHAs may have to adjust their thinking--and policies, procedures and training--on this issue. "I don't believe too many agencies thought about the need to provide a HHABN with the use of telehealth or nutrition services," Adams says.

Silver lining: The good part of this instruction is that agencies will have to implement the same process for all services, regardless of Medicare coverage, Zuber notes. "It's easier to have one process and stick with it no matter who's paying," she tells Eli.

• Assessment visits. If you conduct an assessment visit and decide not to admit the patient, whether you issue an ABN depends on whether you charge for the visit.

If you don't charge anyone for the assessment, no ABN is necessary, CMS says in Q&A #17. If you do charge, then an ABN is necessary.

Note: The Q&As are at www.cms.hhs.gov/BNI/03_HHABN.asp- scroll down to "Downloads."