Tulane University Medical Group

1
Tulane University Medical Group

• Compliance Education and Training
• One Compliance Credit is earned for
• viewing the presentation and completing the
• quiz (download the quiz before viewing the
  presentation).
• For problems downloading this presentation,
  please call Charlotte Corbin at 504-988-7721 or
  ccorbin_at_tulane.edu

2
Medicare ABNs

• (Advance Beneficiary Notice)

3
The Advance Beneficiary Notice is

• a written notice which a physician (or supplier)
  gives to a Medicare beneficiary
• is intended to inform a beneficiary before he or
  she receives specific services (or items) that
  otherwise might be covered by Medicare that
  Medicare probably will not pay for them on that
  occasion
• designed to allow the beneficiary to make an
  informed decision whether to receive the services
  or items for which he or she may have to pay
  out-of-pocket, or through other insurance

4
Summary of Exclusions from Medicare Benefits

• Personal comfort items
• Routine physicals and most screening tests
• Most vaccinations
• Routine eye care, eyeglasses and examinations
• Hearing aids and hearing examinations
• Cosmetic surgery

• Most outpatient prescription drugs (unless
  patient has Medicare D)
• Dental care and dentures (most cases)
• Orthopedic shoes and foot supports
• Routine foot care
• Health care received outside the USA

5
More Exclusions

• Services by immediate relatives
• Services required as a result of war
• Services under a physicians private contract
• Services paid for by a non-Medicare government
  entity
• Services for which the patient has no legal
  obligation to pay

• Home health services furnished under a plan of
  care, if the agency does not submit the claim
• Physicians services performed by a physician
  assistant, midwife, psychologist, or nurse
  anesthetist, furnished to an inpatient, unless
  furnished under arrangements by the hospital

6
And

• Items and services furnished to a resident of a
  skilled nursing facility (SNF) or part of a
  facility that includes a SNF, unless they are
  furnished under arrangements by the SNF

• Services of an assistant at surgery without prior
  approval from the peer review organization
• Outpatient occupational and physical therapy
  services incidental to a physicians services

7
How do I decide if an ABN is needed?

• The following information is from What Doctors
  Need to Know about the ADVANCE BENEFICIARY
• NOTICE (ABN) published by
• the Medicare Learning Network
• http//cms.hhs.gov/medlearn/refabn.asp

8
Will Medicare deny payment for this service?

• No, I do not expect Medicare to deny payment
• I dont know. I never know what Medicare will
  deny

• Do not give any ABN. Do submit a claim to
  Medicare.
• If Medicare pays, you may collect charges from
  Medicare, and any coinsurance deductible from
  the patient.
• If Medicare denies payment for medical necessity,
  you may
• Provide additional documentation of medical
  necessity
• Appeal on the basis that the service should be
  covered
• Appeal on the basis that you could not reasonably
  have been expected to know Medicare would not pay
• If Medicare denies payment based on a statutory
  exclusion or failure to meet technical coverage
  requirements under the program benefits section
  of the law, YOU MAY COLLECT FULL CHARGES FROM THE
  PATIENT.

9
Yes, I have a genuine reason to expect Medicare
to deny payment. Ask, On
what basis do I expect Medicare to deny?

• MEDICAL NECESSITY
• Denial as not reasonable and necessary
• Do give an ABN. If the patient receives the
  services or items, you must always submit a claim
  to Medicare (called a demand bill)
• If you do not submit a claim you violate the
  mandatory claims submission provision, which can
  result in sanctions

• EXCLUSIONS TECHNICAL DENIALS
• All other exclusions from medicare benefits, and
  failure to meet technical coverage requirements
• Do not give an ABN. You do not need to submit a
  claim unless the patient demands it
• If you do not submit a claim, you may collect
  full charges from the patient.
• And.

10
When (or If) you submitted a claim,

11
If Medicare Pays

• Collect payment from Medicare, and any
  coinsurance and deductible from the patient.
• On an unassigned claim, you may also collect up
  to a 15 balance billing amount from the patient.

12
If Medicare denies payment

• You may collect full charges from the patient.

13
EMTALA (Emergency Medical Treatment and Active
Labor Act)

• Designed to combat discriminatory practices of
  some hospitals transferring, discharging, or
  refusing to treat indigent patients coming to the
  emergency department because of high costs
  associated with diagnosing and treating them.

14
EMTALA (Emergency Medical Treatment and Active
Labor Act)

• Requires that
• Hospitals must provide appropriate medical
  screening exams (MSE) to anyone coming to the
  E.D. seeking medical care
• When the hospital determines that the patient has
  an emergency medical condition, the hospital must
  treat and stabilize the medical condition, or
  must transfer the patient
• A hospital must not transfer a patient with an
  emergency medical condition who has not been
  stabilized unless conditions are met that include
  effecting an appropriate transfer

15
EMTALA (Emergency Medical Treatment and Active
Labor Act)

• If you see a patient in a setting and in
  circumstances to which EMTALA provisions apply,
  ASK,
• Has a Medical Screening Examination (MSE) by a
  qualified individual been completed?

16
No, the MSE is not complete.

• 1. Do not give an
• ABN.
• 2. First, complete an
• MSE.
• 3. Stabilize the patient.
• 4. Then give an ABN,
• but only if appropriate.

• 1. Do not give an ABN
• 2. If you do not complete
• an MSE, no ABN may
• be given

17
Yes, the MSE is complete.

• Is the patient stabilized?
• No. Yes.
• 1. Stabilize the patient. Give an ABN, but
• only if appropriate.
• 2. Give an ABN, but only
• if appropriate.

18
Do not routinely give ABNs to all emergency
department patients

• who are Medicare beneficiaries.
• Even after a patient has received an
• MSE and is stabilized, do not give the
• patient an ABN unless you have a
• genuine reason to expect Medicare to deny
• payment for the services.
• Giving routine ABN notices is a prohibited
• practice.

19
To earn credit for this material,

• Download the quiz at www.__________.
• Print the quiz and answer the questions.
• Fax the completed test to the HIPAA Compliance
  Office at 504-988-7777, or send it through Campus
  Mail to TW-3.
• If you have any questions, email M. Reina, Senior
  Director, TUMG Business Services, at
• mreina_at_tulane.edu .