Medicare Compliance & Reimbursement

If you still struggle with understanding the difference between the ABN and the NEMB forms for durable medical equipment and hospice services, your prayers have been answered.

In March, the Centers for Medicare & Medicaid Services unveiled its new advance beneficiary notice. The new form replaces both the previous ABN-G (for DME suppliers, hospices, part B therapy and other providers like physicians) and ABN-L (for laboratories) and incorporates the notice of exclusions from Medicare benefits (NEMB) form. CMS expects this new, combined ABN form to "eliminate any widespread need for the NEMB in voluntary notification situations," according to the new ABN Form Instructions document.

Then: In case you weren't familiar with exactly when you were supposed to use the ABN rather than the NEMB, keep in mind that in the past, ABNs were only for equipment or services that Medicare might not cover but didn't apply to items or services that were statutorily excluded from Medicare benefits. That was where the NEMB came in -- you were able to use it for services such as therapy services beyond the Part B therapy caps (that didn't fall under an exception) because Medicare never covered them.

Now: CMS will accept the new ABN form for either purpose, noting in its ABN Instructions that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

Don't worry: Although Medicare contractors began accepting the new ABN form on March 3, CMS has implemented a six-month transition period. Therefore, you aren't required to submit the new form until Sept. 1.

DME suppliers should be especially aware of the new ABNs, CMS urges in a recent email to providers.

Competitive bidding will make these documents crucial for non-contract suppliers, the agency expects.

"Given the range of situations wherein Medicare may or may not pay for a specific item of DMEPOS, it is imperative that non-contract suppliers understand the significance of issuing or not issuing an ABN to beneficiaries to whom they are furnishing a competitively bid item," CMS says in the message.

In other words, if your patient wants to stick with you under bidding, even though you're not a contract supplier, he or she must agree to pay privately for the equipment. But you can't collect the money from the beneficiary unless she has signed a valid ABN.

Exception: Home health agencies don't have to worry about the new ABN-G forms. They use their own separate home health ABN form.

Although the ABN form has changed, many of the previous ABN "best practices" remain the same. These three important ABN facts that could save your billing.

1. Understand the function of the ABN. If you discover that a patient's equipment or services may not be payable by Medicare, but the patient still wants them, the ABN will let the patient know that he or she may be responsible for paying the non-covered portion, and you're required to issue an ABN in this case.

If, however, the item or service you're providing is statutorily non-covered by CMS, you can choose to voluntarily provide the patient with the revised ABN, notifying her that this service is not covered by Medicare and that she is responsible for payment -- in other words, exactly how you would have handled the situation using an NEMB form.

Remember: ABNs help patients decide whether they want to proceed with an item or service even though they might have to pay for it. A signed ABN ensures that you will receive payment directly from the patient if Medicare refuses to pay. Without a valid ABN, you cannot hold a Medicare patient responsible for the denied charges, says Kara Hawes with Advanced Professional Billing in Tulsa, OK.

2. Keep fresh copies of the ABN close by. "The patient has to sign the ABN form at the time of service, otherwise the form is not valid," Hawes says. "When the claim is denied without an ABN, Medicare will not allow you to be reimbursed for the service or collect money from the patient."

3. Explain the ABN to the patient. ABNs help the patient understand his options. Once you have completed the ABN and discussed it with the patient, he can: 1) sign the ABN and assume financial responsibility for the items or services in question; 2) cancel the equipment or services; or 3) reschedule the item or services for future dates when he can afford it, or when Medicare may cover them.

Note: The new ABN and instructions, including a Spanish-language form, are at http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp.