ABNs: What NOT to Do
By G.J. Verhovshek, MA, CPC
The Centers for Medicare & Medicaid Services (CMS) recently released a new Advanced Beneficiary Notice of Noncoverage (ABN), making it a perfect time to refresh your understanding of this form and make sure you are using it appropriately.
The ABN is a standard form that a medical practice can use to inform a patient that Medicare may deny coverage for a recommended or desired item or service. It explains why Medicare may deny the item or service, and provides a cost estimate for it. An ABN also notifies the patient of his responsibility to pay for the noncovered item or service, if he chooses to receive it. In many cases, a provider cannot seek payment from the patient for unpaid Medicare services if an ABN was not properly issued.
CMS periodically revises the ABN. The most recent version, Form CMS-R-131 (release date March 2011), is mandatory as of Jan. 1, 2012. Previous versions of the ABN (release date March 2008) are no longer being accepted. The “Revised ABN CMS-R-131 Form and Instructions” may be downloaded from the CMS website.
ABNs must be reproduced on a single page (either letter or legal size). To be safe, reproduce the ABN “as is” from the CMS website; except where specifically allowed by the form instructions, “to integrate the ABN into other automated business processes,” you may not customize the ABN.
How NOT to Use an ABN
Do not use an ABN to bill a patient for additional fees beyond what Medicare reimburses for a given procedure or service. The ABN does not allow the provider to shift liability to the beneficiary when Medicare payment for a particular procedure or service is bundled into payment for other covered procedures or services. An ABN should never be applied as a Band-Aid® cure to gain payments in spite of sloppy coding, or as a way to “game” Medicare beneficiaries.
ABNs Are NOT Required in an Emergency
ABNs are never required in emergency or urgent care situations. CMS policy prohibits giving an ABN to a patient who is “under duress,” including patients who need emergency department services before stabilization.