Wiki ABN for Managed Care Plan

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TJAlexander

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I don't have a ton of experience with billing Managed Care Plans that we are out of network for so when we received a denial from a small carrier for being OON, I billed the patient. The carrier then contacted me to advise that since we did not have the patient sign a waiver that we could not bill her for the services. Can someone help me understand how this works? We billed the carrier 99213, 71020, 96372 and J1100(10). Are we obligated to have a patient sign a waiver for a simple office visit? I thought that only applied to procedures listed in the HCPCS Addendums? Also, do waivers apply to managed care companies like Aetna, Humana and other companies that administer Medicare benefits? I thought ABN's were necessary for Medicare only.

Please help!

Thanks....
 
Yes, ABNs generally apply to regular Medicare only. But I assume in this case you're speaking of a Managed Care Medicare plan? If so, your providers are generally required to comply with the terms of that plan even if you are not contracted, unless there were extenuating circumstances that prevented you from being able to know the terms of the plan in advance. Here's a good article that explains it in more detail:

http://www.mgma.com/government-affa...what-is-deeming-under-medicare-advantage-mgma

So even if you are not contracting, you're legally required to follow that plan's rules and cannot balance bill the patient. If this is a managed care commercial plan, on the other hand, then you are not under any contractual or legal obligation to waive the patient's responsibility.
 
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