Practice Management Alert

Question: Are there any waivers for use when the physician provides an experimental and non-covered service to a patient with a private insurer? I was wondering if I could use Medicare's advance beneficiary notice (ABN) to ensure payment. Or is there some other template I could use?

Oregon Subscriber

Answer: When your physician provides a service that the patient's private insurance may not cover, there are some things you can do to improve your chances of reimbursement.
 
Example: Endoluminal gastroplication (ELGP) is a new treatment for gastroesophageal reflux disease (GERD). Many insurers still consider it an experimental procedure, and CPT 2006 lists ELGP in its Category III code set (0003T-0140T).
 
Suppose a gastroenterologist is scheduling ELGP for a GERD patient with private insurance. Before filing the ELGP claim with 0008T (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate, with suturing of the esophagogastric junction), the gastroenterologist should take extra steps to make sure he gets paid if the carrier denies the claim.
 
Consider these two methods for ensuring payment on potentially non-covered services:
 
1. Require the patient to pay in advance. Use this tactic only if you are completely sure the carrier will not cover the service. If the patient expresses concern over paying the bill, arrange a prospective payment plan with the patient before providing the service.
 
2. Formulate an ABN-like waiver and get the patient to sign. Some carriers have their own ABN-type forms; call and ask a representative if the carrier provides a standard waiver for potentially noncovered services. If the carrier does not have its own waiver, you can create one based on Medicare's ABN.
 
In the waiver, be sure you:
 - provide a written summary of the patient's benefits.
 - describe, in detail, the specific service that the carrier may deny.
 - make it clear to the patient that he is responsible for any of the costs his carrier does not cover for the service.

Once the patient signs, give him one copy of the waiver and keep the original with the patient's chart.