Optometry Coding & Billing Alert

Published on Fri Nov 11, 2005 PDF

Question: We have a patient who signed an advance beneficiary notice, and as we suspected, Medicare won't pay for the services. Now the patient is saying she didn't understand what the ABN meant and is refusing to pay. What should I do?


California Subscriber


Answer: The patient must pay. An ABN is a written notice a provider gives a Medicare beneficiary before furnishing items or services when the provider believes that Medicare will not pay on the basis of medical reasonableness or necessity.

Keep these additional factors in mind:

Making informed decisions: The patient has already been put on notice that Medicare coverage is unlikely. With this information, the patient is then in a better position as a healthcare consumer to make an informed decision about what services he may have to pay for out of pocket or through other insurance.

Improperly issued ABNs: When issuing an ABN, the provider must advise the Medicare beneficiary that he will be personally and fully responsible for payment of all items and services specified on the ABN if Medicare denies the claim. Be aware that an ABN is considered improperly issued when:

- The provider refused to answer inquiries from a patient or his authorized representative.

- An ABN was used to shift liability to the beneficiary for items or services when full payment for those items or services is bundled into other payments.

In most situations, though, you should simply remind the patient that she has signed the ABN and that it was explained at that time that she must pay if Medicare doesn-t. Suggest that she contact Medicare if she has further questions.

Good advice: For post-cataract glasses, collect the noncovered charges for frames and lens add-ons like tints and material upgrades (such as polycarbonate) at the time you order the glasses. It is much easier to hold the job until the patient pays the required charges than try to collect from an uncooperative patient later.

Advice for Reader Questions and You Be the Expert contributed by David Gibson, OD, FAAO, practicing optometrist in Lubbock, Texas; and Charles Wimbish, OD, president of Wimbish Consulting Group in Martinsville, Va.