Wiki Medical Necessity for Medicare Outpatients

[mhrivero]

Would like to know if most facilities/practices routinely assess medical necessity for all Medicare outpatient services? If yes, what is your process for checking medical necessity and providing the patient with an Advance Beneficiary Notice of Noncoverage (ABN) when there is reason to believe that Medicare is likely to deny payment based on CMS guidelines.

 

[TThivierge]

Hi Mhrivero
It use to be a form gave Medicare patient in which they signed know which not covered services. But maybe can add a paragraph or phrase on E signed consent if have the Medicare A & B coverage. Or just add electronic statement at end of consent area let them check it off or what items or service not covered so they are aware. Your IT department should be able to add it
I hope this data helps you
Lady T

 

[mhrivero]

Hi Mhrivero
It use to be a form gave Medicare patient in which they signed know which not covered services. But maybe can add a paragraph or phrase on E signed consent if have the Medicare A & B coverage. Or just add electronic statement at end of consent area let them check it off or what items or service not covered so they are aware. Your IT department should be able to add it
I hope this data helps you
Lady T

Hi and thank you so much for your response! Just have a follow up. I found the info below on the AAPC site when I searched for ABN information. Since the ABN is required for certain services to bill the patient, do you use the actual ABN form in those instances? Or, something else?

Required
The service or item is a benefit of Medicare (normally payable) but due to restricted coverage will not be paid. For example:

• Therapy services that have exceeded the cap amount
• Exceeded frequency limits
• Not reasonable or necessary (ex: diagnosis restriction)
• Skilled nursing services for a patient who is not homebound

Voluntary
The service or item is not a benefit of Medicare (never payable). The use of the ABN in this circumstance is a courtesy to the patient, so that the patient can make an informed decision prior to the service being rendered. It also allows your office to provide documentation in case the cost of the service to the patient is questioned at a later date.

 

[ggoode66]

Are you the outpatient center where the procedures are going to be done?
You are really talking about two different things, what the provider believes is medically necessary and what CMS believes is medically necessary.
if for example you are an imaging center where the patient is coming into your facility to have the procedure done. During the initial scheduling, are you going over their out of pocket cost's if any? it would be at this time when the ABN would be signed or acknowledged, depending on how you handle documenting a patient has been given your instructions.