Medicare Compliance & Reimbursement

Insufficient notices can land providers in hot water.

Providers who don't understand the ins and outs of the new home health advance beneficiary notices could run into trouble with surveyors.

Home health agencies must master the new advance beneficiary notice requirements, cautions Burtonsville, MD-based attorney Elizabeth Hogue. That's because the Centers for Medicare & Medicaid Services clearly specifies that agencies will be violating the Medicare conditions of participation if they don't adhere to ABN requirements.

Here are vital facts every provider should know about the new ABNs:

• CMS requires providers to use the new forms by May 31. But agencies "should consider switching to the new HHABN as soon as possible," CMS says on its ABN Web site.

• Agencies must issue the notices at three trigger points: (1) when initiating non-covered care, (2) when reducing non-covered or covered care, and (3) when terminating non-covered care.

• Agencies have two ABN options and forms to choose from. They issue the second option when reducing or terminating care for their own financial or other reasons, like staffing shortages. Option 1 "is used in all other cases," CMS instructs.

• Beneficiaries can choose one of three responses when they receive an Option 1 ABN: (1) reject services Medicare won't pay for, (2) privately pay for services, or (3) bill other insurers. When beneficiaries receive an Option 2 ABN, the patient can try to obtain services from another agency.

• Benes must sign and date the ABN, then the agency keeps the original and gives the copy to the beneficiary. HHAs don't have to deliver the notice in person, CMS clarifies.

• HHAs can charge benes upfront when patients choose to bill Medicare or other insurers under Option 1, the form specifies.

• Agencies must explain in plain language why they believe Medicare won't cover care. The stated reasons must "allow the beneficiary to fully understand the basis for the HHA's conclusion regarding probable non-coverage, thereby letting the beneficiary make an informed choice about accepting financial liability," CMS directs. "As examples, the information must convey more than simply that care is 'not reasonable or necessary' or 'not a Medicare benefit'. If such conditions are thought to apply, state why they apply."

The new ABN forms and instructions are at www.cms.hhs.gov/BNI/03_HHABN.asp.