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Practice Management Alert

Advance Beneficiary Notice Must Qualify as Timely

Published on Sat Jun 01, 2002

If you do not provide the patient with a "timely" advance beneficiary notice (ABN) timely being defined as far enough in advance of receiving the medical service that the patient has enough time to make a rational, informed decision you cannot bill the patient if Medicare denies payment.

Note: For more on ABNs and the billing process, see the May 2002 Medical Office Billing and Collections Alert.

CMS says a timely ABN:

  • should ideally be hand-delivered to the patient before the service is performed. A telephone call informing the patient a service may not be covered is not adequate notice. Neither is giving an ABN to a patient connected to a testing device or in the process of receiving a service. No matter how well-meaning your intentions, CMS considers this behavior coercive.
  • must specify why you expect that Medicare may deny payment. This allows the patient to make an informed decision about whether to proceed with the service and pay for it out-of-pocket.
  • must not be routinely distributed for all claims and services. A routine statement to the effect that you can never be sure when Medicare might deny a claim is insufficient.

    Patient Must Comprehend Statement

    To be legal, the patient must be able to comprehend the ABN. A patient is unable to understand if he or she is:

  • comatose
  • confused, e.g., experiencing confusion due to senility, dementia, Alzheimer's disease, etc.
  • declared legally incompetent, under great duress, or in a medical emergency
  • unable to read the language in which the notice is written
  • blind or visually impaired and cannot see the words on the printed page
  • deaf and cannot hear an oral notice
  • unable to speak to ask questions about the printed form without help of a translator.

    In such situations,a relative or other legally authorized person may sign the form on the patient's behalf. If the person has a language barrier, you could have the notice translated orally or into print. For patients who have visual impairments, you could set the ABN in extra-large type or in Braille. For a hearing-impaired client, a sign-language interpreter can be secured.

    If the patient or his or her representative decides not to sign the ABN, you should make a note on the form indicating the circumstances and individuals involved in the decision. In such cases, you may choose not to furnish these services to the patient because he or she has not agreed to be financially responsible should Medicare deny the claim.

    Even when a patient signs an ABN, you must still submit the claim to Medicare. But first, ask the carrier if you should submit the ABN with the claim or simply indicate on the bill that one exists.

    Once Medicare denies the claim, you are free to bill and collect from the patient. $ $ $

     

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