Professional Assoc. of Healthcare Coding Specialists PAHCS Presented by Marge McQuade, CMSCS, CMM, CPM Director of Education

Transcription

1 Advanced Beneficiary Notice ABN Professional Assoc. of Healthcare Coding Specialists PAHCS Presented by Marge McQuade, CMSCS, CMM, CPM Director of Education

2 EFFECTIVE MARCH 1, 2009 Providers must notify patients in advance of their responsibility and give the patient an estimated cost up front. The new form replaces the General Use ABN and the Lab ABN.

3 Advanced Beneficiary Notice of Noncoverage (ABN) May be used for voluntary notifications in place of Notice of Exclusion from Medicare Benefits Has a mandatory field for cost estimates of the items/services at issue Includes a new patient option which allows the patient to choose to receive service and pay outof-pocket rather than have a claim submitted to Medicare

4 ABN CHANGES Previously the ABN was only required for denial reasons the revised version of the ABN may also be used to provide voluntary notification of financial liability. This version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB) in voluntary notification situations.

5 ABN GUIDANCE The ABN must be verbally reviewed with the patient or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the patient or representative has time to consider the options and make an informed choice. ABNs are never required in emergency or urgent care situations.

6 FILLING OUT THE FORM There are 10 blanks for completion in this notice. Blanks (A)-(F) and blank (H) may be completed prior to delivering the notice, as appropriate. Entries in the blanks may be typed or hand-written, but should be large enough to allow ease in reading. The Option Box, Blank (G), must be completed by the patient or his/her representative. Blank (I) should be a cursive signature, with printed annotation if needed in order to be understood. Once all blanks are completed and the form is signed, a copy is given to the patient or representative. In all cases, the physician's office must retain the original notice on file.

7 THE FORM

8 OPTION 1 OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. This option allows the patient to receive the items and/or services at issue and requires the physician's office to submit a claim to Medicare. This will result in a payment decision that can be appealed.

9 OPTION 2 OPTION 2. I want the (D) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. This option allows the patient to receive the noncovered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.

10 OPTION 3 OPTION 3. I don t want the (D) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. This option means the patient does not want the care in question. By checking this box, the patient understands that no additional care will be provided and thus, there are no appeal rights associated with this option.

11 Additional Info The patient or his or her representative must choose only one of the three options listed in Blank (G). Under no circumstances can the physician's office decide for the patient which of the 3 checkboxes to select. Pre-selection of an option by the physician's office invalidates the notice. However, at the patient s request, physician's offices may enter the patient s selection if he or she is physically unable to do so. In such cases, physician's office must annotate the notice accordingly.

12 ADDITIONAL INFO If there are multiple items or services listed in Blank (D) and the patient wants to receive some, but not all of the items or services, the physician's office can accommodate this request by using more than one ABN. The physician can furnish an additional ABN listing the items/services the patient wishes to receive with the corresponding option. In a case where the physician's office that gives an ABN is not the entity that ultimately bills Medicare for the item or service (e.g. when a physician issues an ABN, draws a test specimen, and sends it to a laboratory for testing), the physician's office MUST give a copy of the signed ABN to the billing entity. Retention is required in all cases, including those cases in which the patient declined the care, refused to choose an option, or refused to sign the ABN

13 Effective Time Frame An ABN can remain effective for up to one year. ABNs may describe treatment of up to a year s duration, as long as no other triggering event occurs. If a new triggering event occurs within the 1- year period, a new ABN must be given.

14 WHERE TO GET THE FORM & INSTRUCTIONS Medicare Claims Processing Manual, Publication , Chapter 30, 50. OMB-approved ABNs are placed on the CMS website at:

15 Contact Information If you have questions please contact Marge McQuade, CMSCS, CMM, CPM PAHCS Director of Education