Medicare Compliance & Reimbursement

Check out these must-know vitals on cost estimates and pre-printed information.

If home health agencies (HHAs) fail to fill out the new home health advance beneficiary notice (ABN) correctly, they could be financially liable for the services at issue--or even in hot water with surveyors.

The Centers for Medicare & Medicaid Services (CMS) hasn't been clear on who will enforce the new ABN rules and forms that take effect June 1. That means HHAs need to be especially cautious when protecting themselves against ABN non-compliance, urged the National Association for Home Care & Hospice's Mary St. Pierre in a May 9 teleconference on the new notices.

Trap: One important factor you may overlook is what to put in the "because" section of Option Box 1, St. Pierre warned. When you are going to continue furnishing services to the patient, you must be especially vigilant to fill out that blank on the ABN correctly or risk financial liability for the services at issue.

In the "because" blank, you must explain why Medicare won't cover--and pay for--services. HHAs issue the ABN either before initiating care or when care is reduced or terminated from originally ordered levels.

Don't Confuse Beneficiaries With Lingo

"The reasons provided must be in plain language and allow the beneficiary to fully understand the basis for the HHA's conclusion regarding probable noncoverage, thereby letting the beneficiary make an informed choice about accepting financial liability," CMS emphasizes in its new ABN instructions. "The information must convey more than simply that care is 'not reasonable or necessary' or 'not a Medicare benefit.'"

If you fail to explain the reason for non-coverage in plain language the patient can understand, you could end up on the financial hook for the care referenced in the notice, St. Pierre cautioned. Reviewers of a beneficiary appeal may find the notice isn't valid, for example, if your explanation uses a lot of abbreviations the patient wouldn't understand, she said.

Other aspects to keep in mind to fill out the ABN correctly include:

• Cost estimates. In usual cases, agencies should fill out the total cost estimate for all visits covered by the ABN when filling out Option Box 1, St. Pierre advised.

The exception: However, if you have no physician orders for the care and so wouldn't be able to provide it, you can furnish just a per-visit cost for the disciplines at issue, CMS has told NAHC.

• Pre-printed information. The more information agencies can print on forms beforehand, the better the accuracy and the less time they will take for clinicians to fill out. However, CMS discourages using pre-printed information to offer multiple choices that the clinician chooses from, St. Pierre reported.

CMS will, however, permit some options to be pre-printed in the blanks of ABN Section B, including the choices "will not," "will only" and "will no longer provide you" in the second blank. In that case, you should circle the language that applies AND scratch out the language that does not apply, St. Pierre instructed.

You can also pre-print the name of your agency in the first blank of Section B and the list of services that may be reduced or terminated in the third blank of section B, NAHC reports. Again, you must circle the services that apply and cross out those that don't, St. Pierre counseled.

Keep in mind: Any pre-printed information in the blanks must be in at least 10 point font, CMS directs in the ABN instructions. Information in the blanks can also be typed or "legibly hand-written," the agency says.

• Header. HHAs wanting to get more organized by adding information to the ABN header section are out of luck. Agencies may include only their contact information and logo in the header, CMS has told NAHC. They can't add items like record numbers or the name of the clinician filling out the ABN because it may confuse the beneficiary, CMS maintains.