Advanced Beneficiary Notice: Shift Responsibility to Patients the Correct Way

by Belinda S. Frisch, CPC

An Advanced Beneficiary Notice of Non-coverage (ABN) is a form for Medicare beneficiaries to notify them that Medicare is not likely to cover specific services. It is not used for Medicare Choice beneficiaries or non-Medicare patients.

A new form, CMS-R-131, was created to blend together former ABN-L and ABN-G forms. The form contains several new fields, including cost estimate, and must be used by providers no later than Sept. 1, 2008.

What Does an ABN Do?

The ABN serves two purposes:

1. It encourages Medicare beneficiaries to make informed consumer decisions about their medical care. It provides beneficiaries the chance to opt out of non-covered services and informs them of their financial responsibility should Medicare deny payment.

2. It shifts payment responsibility from the provider to the patient. Delivering an ABN-covered service  without a signed ABN and appropriate modifier will cause Medicare to deny the services as the provider responsibility (PR) aka a write-off. Obtaining the ABN and billing the line item with modifier GA Waiver of liability statement on file generates a PR denial which allows the patient to be billed and lists the charge as their responsibility on their OWN copy of the Explanation of Medicare Benefits.

How is it Delivered?

CMS is very clear about how and when to deliver an ABN.

1. Verbally review the ABN with the beneficiary or their representative and answer any questions  before the ABN is signed.

2. Do not change the ABN forms from the Office of Management and Budget (OMB)-approved format except for where allowed by customizable fields.

3. Deliver an ABN with enough time before the service rendered for the beneficiary to consider and make an informed consumer decision.

4. Never use ABNs in emergency or urgent care situations.

5. Reproduce ABNs on a single page.

6. Complete all blanks, including estimated cost, and the patient’s signature. Give a copy of the form to the beneficiary and  retain the original in the patient’s file.

What Reasons Should I Put on an ABN?

Clearly state on the ABN why Medicare may not pay for the services. Reasons may include (but are not limited to) the following:

  • Medicare does not pay for these tests for your condition
  • Medicare does not pay for these tests as often as this (denied as too frequent)
  • Medicare does not pay for experimental or research use tests
  • Medicare does not consider these services to be reasonable or medically necessary

Modifier GA and ABNs

Use modifier GA to report a waiver of liability, or ABN, on file.

Append GA to the line item which the beneficiary signs for EVERY TIME an ABN is signed. Failure to do so, results in Medicare inappropriately determining PR (write off) for the denied charge.

If the modifier GA is present, Medicare notifies the patient of their financial responsibility and the provider can legally bill the beneficiary for the balance due.

More Information: If a patient needs help understanding the ABN process, the new ABN form includes the telephone number 1-800-MEDICARE under the “additional information” section.

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