Navigating the Updated Medicare Advance Beneficiary Notice Regulations

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Medicare ABNs CMS Updated Rules and Guidelines

• Presented by
• David M. Vaughn, Esq., CPC

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What is an ABN

• Advanced Beneficiary Notice
• Notice to the Pt he/she may have to pay out of
  pocket
• If Medicare doesnt pay, the Pt is responsible
• ABNs are Medicare FFS Only
• Medicare Advantage Plans do not use ABNs
• They use Organization Determinations
• Which are advance coverage determinations
• If coverage denied, get a commercial ABN

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Retroactive ABNs

• Cant backdate ABN
• Cant make ABN retroactive for prior DOS
• Summary
• ABN for future DOS yes
• ABN for prior DOS no

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What Services Do ABNs Apply To?

• Part A (inpatient) Yes
• Hospital, hospice, home health agencies
• Part B (outpatient) Yes
• Physicians, SNFs, home health agencies
• Part C (Medicare Advantage) No
• Part D (Medicare drug plans) No

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What Form Do You Use?

• Physicians CMS-R-131
• SNFs ABN for Part B CMS-10055 is Part A
• Hospital Issued Notice of Noncoverage (HINN)
• HINN 1 entire hospital stay noncovered
• HINN 10 hospital requests Quality Improvement
  Org. to review discharge decision (can be use for
  MA)
• HINN 11 noncovered items during covered stay
• HINN 12 noncovered continued stay

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Filling Out the ABN

• F Estimated cost to Pt must be w/i 100 or 25
  of actual
• G Pt Options
• Option 1 Bill Medicare
• Option 2 Dont Bill Medicare
• Option 3 I dont want the service
• H Optional addl information
• I Pt signature
• J Date (by the patient)

• A Notifier Your name, address, Tel.
• B Patient name
• C Optional internal ID
• D The noncovered service
• 7 places for D on the ABN
• E Reason for Medicare denial
• Medicare doesnt pay for this test
• Medicare doesnt pay for this test as often as
  this (denied as too frequent)
• Medicare considers this investigational or
  experimental

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Coercion

• The following is considered coercive
• Giving Pt an ABN in the ER
• Giving Pt an ABN in an emergency
• Giving Pt an ABN in ambulance, unless not in an
  emergency situation
• Probably giving ABN on the DOS

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What About Medicare Advantage?

• Medicare Advantage
• They are required to follow Medicare LCDs
• Regardless, they dont accept ABNs
• They use Organization Determination
• This is a prepayment determination

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What About Commercial Payers?

• Do not use ABNs
• ABNs are for Medicare FFS
• Can use a commercial ABN
• Patient signs a form agreeing to self-pay
• You can use an ABN-like form
• Has the service, the fee, etc.

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What if No Commercial Coverage?

• Must use the No Surprises Act (NSA)
• Notice of Right to Receive Good Faith Estimate
• Good Faith Estimate itself
• CMS has template forms for both of these
• NSA does not apply to Medicare FFS
• You use the ABN
• NSA does not apply to MA or Medicaid

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Prohibited Use of ABNs

• Cant use an ABN to
• Shift liability to Pt to circumvent an MUE edit
• Shift liability to Pt to circumvent a bundling
  edit
• Coerce Pts in an emergency situation
• Concierge services, staff time filling out forms

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When You Must Issue ABN

• When the service isnt reasonable or necessary
• Service is investigational or experimental
• Medicare frequency limits are exceeded
• Outpatient therapy exceeds allowed amount
• LCD says a service isnt payable at all, or
• Only if certain circumstances exist, which are
  not met

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Modifiers

• GA use when you have a mandatory ABN
• GX use when you issue a courtesy ABN for items
  Medicare never covers combine with GY
• GY use for statutorily noncovered items use
  with GX
• GZ use when you expect Medicare to deny and you
  didnt get an ABN
• GK use when upgrading a piece of equipment
• GL same as GK but you didnt get an ABN

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Collecting Refunding Patient Payments

• You can seek Pt payment up front when you have a
  signed ABN
• However, if Medicare pays anyway
• You must refund the Pt in a timely manner
• Medicare considers 30 days after the RA timely
• Civil monetary penalties issued for late refunds
• 2,000/day

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Courtesy ABNs

• As a courtesy, you can give Pt ABN
• For an items that Medicare never covers
• Cosmetic surgery
• ABN not a requirement, just a courtesy

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Routine ABNs

• Routine ABNs not allowed except for
• Experimental items
• Items with frequency limitations
• Medically unnecessary services
• DME where supplier has no supplier

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Electronic vs Paper ABNs

• Electronic ABNs are not prohibited, but
• The patient has the right to request paper copy
• Medicare wants ABNs delivered in person, but if
  it cant be, then email, fax, or mail is ok
• The Pts signature can be electronic
• If the ABN is electronic, you can scan your
  signed copy into your EHR
• Pt is given a paper copy for their records

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