Medicare Compliance & Reimbursement

Tip: Use patient-friendly language when creating ABNs.

Last year, the feds released an updated advance beneficiary notice (ABN) form with a summer release date, then extended the start date to Jan. 1, 2021. The new form is now required, but confusion still exists on the logistics. Read on for details and insight.

Then: The Centers for Medicare & Medicaid Services (CMS) debuted an updated ABN that providers were required to use as of Aug. 31, 2020; however, the agency published a pandemic exception pushing the start date out. “At this time, the renewed ABN will be mandatory for use on 1/1/2021,” CMS advised in a release. “The renewed form may be implemented prior to the mandatory deadline,” the agency offered.

Now: If you aren’t sure whether you’re using the newest form, check the bottom left of the document. It should say “Form CMS-R-131 (Exp. 06/30/2023),” signifying that you’re using the correct ABN.

Details: According to CMS, new forms were necessary to address dual eligibility for beneficiaries. The agency wanted to offer additional guidelines for patients who are covered by both Medicare and Medicaid, also known as dual eligible beneficiaries. These patients cannot be charged for Medicare cost-sharing when they receive services under Medicare Part A or Part B.

“Dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication,” the new ABN guidelines state. “Strike through Option Box 1 as provided below:”

• OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.

Here’s Why the Update Was Necessary

CMS made these edits to solidify the fact that providers cannot bill dual eligible beneficiaries when furnishing the ABN.

“Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual eligible beneficiaries,” CMS says in the ABN instructions.

“If Medicare denies a claim where an ABN was needed in order to transfer financial liability to the beneficiary, the claim may be crossed over to Medicaid or submitted by the provider for adjudication based on State Medicaid coverage and payment policy. Medicaid will issue a Remittance Advice based on this determination,” CMS adds in its guidance.

Bolster ABN Smarts With These Steps

ABNs are often incorrectly completed and deemed invalid by Medicare, which is why it’s critical you fill them out accurately and ensure your patients understand what they’re signing. Consider these best practices on how to utilize the forms in your organization.

Never use “blanket” ABNs to cover yourself just in case a payer denies a service. Instead, you must be sure there is a reasonable basis for noncoverage associated with the issuance of each ABN, CMS says in its publication, “Advance Beneficiary Notice of Noncoverage.”

Providers aren’t required to have a signed ABN on hand for services that are never covered by Medicare. However, for those services that are normally a covered benefit — but may not be covered due to medical necessity, frequency, etc. — a signed ABN is required to obtain reimbursement from the beneficiary.

You must issue the ABN when: You believe Medicare may not pay for an item or service; Medicare usually covers the item or service; or Medicare may not consider the item or service medically reasonable and necessary for this resident in this particular instance.