ABNs: The Why, The What & The When Subscriber Webinar The Plan CMS Benefit Notices Initiative The Advance Beneficiary Notice of Noncoverage (ABN) The Uses: Statutory & Voluntary The Form The Difficulties The Notice of Medicare Non Coverage (NOMNC) When / What / How The Difficulties Actions of the Prudent Hospice When faced with any confusing regulation, the most helpful clarifying question is: What is the intent of this regulation? All Rights Reserved 1
Medicare Beneficiary Notices Initiative (BNI) A CMS initiative intended to extend financial liability protections to both beneficiaries and providers Applies to both Fee for Service (FFS) Medicare and the Medicare Advantage (MA) Programs (different forms and processes) Built on written notices given by providers to communicate information to beneficiaries on financial liability appeal rights and protections https://www.cms.gov/medicare/medicare General Information/BNI/index.html Penalties for Failure to Comply If not issued correctly and timely provider can lose financial protections Deficiency on survey 418.116 Condition of participation: Compliance with Federal, State, and locallaws and regulations related to the health and safety of patients. The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients. If State or local law provides for licensing of hospices, the hospice must be licensed. Beneficiary Portal www.medicare.gov All Rights Reserved 2
What are my rights if I think my services are ending too soon? If you re getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare covered services are ending too soon, you can ask for a fast appeal. Your provider will give you a notice before your services end that will tell you how to ask for a fast appeal. The notice might call it an immediate appeal. You should read this notice carefully. If you don t get this notice, ask your provider for it. With a fast appeal, an independent reviewer will decide if your services should continue. The ABN Purpose of the ABN To provide written notice that Medicare probably (or certainly) won t pay for items or services Information on the ABN includes the items or services that Medicare isn t expected to pay for, an estimate of the costs for the items and services, and the reasons why Medicare may not pay The ABN gives you information to make an informed choice about whether or not to get items or services, understanding that you may have to accept responsibility for payment. Medicare Appeals, Centers for Medicare and Medicaid Services Also provides financial protection for providers All Rights Reserved 3
Mandatory use of the ABN is very limited for hospices. Hospice providers are responsible for providing the ABN when required as listed below for items and services billable to hospice. Hospices are not responsible for issuing an ABN when a hospice patient seeks care outside of the hospice s jurisdiction. Claims Processing Manual, Chapter 30 50.15.3.1 Special Issues Associated with the ABN for Hospice Providers When ABNs Are REQUIRED in Hospice 1. Ineligibility because the beneficiary is not determined to be terminally ill as defined in 1879(g)(2) of the Act; 2. Specific items or services that are billed separately from the hospice payment, such as physician services, are not reasonable and necessary as defined in either 1862(a)(1)(A) or 1862(a)(1)(C); or 3. The level of hospice care is determined to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C), specifically for the management of the terminal illness and/or related conditions. Claims Processing Manual, Chapter 30 50.15.3.1 Special Issues Associated with the ABN for Hospice Providers When ABNs Are NOT REQUIRED 1. Revocations 2. Respite care beyond 5 consecutive days 3. Transfers 4. Failure to meet face to face requirements 5. Room and board cost for nursing facility residents Claims Processing Manual, Chapter 30 50.15.3.1 Special Issues Associated with the ABN for Hospice Providers 6. Discharges for cause 7. Discharge out of service area 8. For medications related but not determined to be reasonable and necessary for palliation & management of terminal condition and related conditions All Rights Reserved 4
Non-Covered Medications, DME or Supplies There is currently no expedited process for a beneficiary to appeal a hospice s decision regarding coverage for something related but not included as reasonable and necessary in the hospice plan of care The only route for beneficiary that wishes to appeal a decision is to submit a form requesting payment directly to Medicare; if denied door to appeal rights is opened A hospice may, however, choose to issue a voluntary ABN Voluntary Use of the ABN however, the ABN can be issued voluntarily in place of the Notice of Exclusion from Medicare Benefits (NEMB) for care that is never covered The voluntary ABN serves as a courtesy to the beneficiary in forewarning him/her of impending financial obligation. When an ABN is used as a voluntary notice, the beneficiary should not be asked to choose an option box or sign the notice. Claims Processing Manual, Chapter 30 50.3.2 Voluntary ABN Uses Billing Considerations for ABNs See billing instructions found in Medicare Claims Processing Manual, Chapter 1, 60.4.1 Outpatient Billing with an ABN (Occurrence Code 32) All Rights Reserved 5
The ABN Form The Form To be considered valid notice Must use the most current OMB approved form Verbiage at bottom Form CMS R 131 (Exp. 03/2020) Form Approved OMB No. 0938 0566 Form must be properly completed and signed by beneficiary / representative Notifier retains original and provides copy to beneficiary Retain original for five years https://www.cms.gov/medicare/medicare General Information/BNI/index.html ABN Form Field Required Fields on Mandatory ABNs Recommended Fields on Voluntary ABNs A. Notifier Y Y B. Patient Name Y Y C. Number Optional Optional D. Good or Service Y Y E. Reason Y Y F. Estimated Cost Y Y G. Option Y N H. Additional Information N/A N/A I. Signature Y Does not have to be signed J. Date Y Does not have to be dated All Rights Reserved 6
After Receiving Information Does Beneficiary Want Service? Option 1 Option 2 Option 3 Yes Yes No Does Beneficiary Want Claim Filed with Medicare? Yes No N/A May Provider Ask for Payment Now? Yes Yes N/A May Beneficiary File an Appeal with Medicare if Claim Denied? Yes N/A N/A Examples Beneficiary has been at GIP level of care in hospice inpatient unit, no longer meets criteria but wishes to remain at that level of care. Beneficiary no longer meets Beneficiary wants daily home terminal status requirement visits by physician but no but wishes to continue under medical necessity care and pay privately.* * Must be allowable under hospice policies and state licensure rules in state patient resides What If Beneficiary Refuses to Complete or Sign the Notice Annotate original copy of ABN indication refusal to sign or choose an option Consider not furnishing item/service unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option. Provide a copy of the annotated ABN to the beneficiary, and keep the original version of the annotated notice in the patient s file What If Beneficiary Does Not Have the Capacity to Sign The ABN must be issued to the existing representative All Rights Reserved 7
What If ABN Cannot Be Delivered in Person May make contact via direct phone conversation, mail, secure fax or e mail Notifier must verify that contact was made in his/her records Telephone contacts must be followed immediately by either a hand delivered, mailed, emailed, or faxed notice. The beneficiary or representative must sign and retain the notice and send a copy of this signed notice to the Notifier for retention in the patient s record. The notifier must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice. If the beneficiary does not return a signed copy, the notifier must document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself. The NOMNC Purpose of the NOMNC To allow beneficiary to Appeal provider decision to terminate services Receive a rapid decision via Expedited Determination (ED) process Be protected from financial liability during the process Two QIOs cover the entire country KEPRO: https://www.keproqio.com/ Livanta: http://www.livanta.com/bfccqio.html NOMNC used in one situation for hospices: when all hospice Medicare services are ending due to lack of terminality All Rights Reserved 8
Situations in which NOMNC Is Not Required Care ending at beneficiary s request or initiative Revocation Transfer Discharge out of service area Discharge for cause Delivery Requirements NOMNC is delivered to beneficiary or representative no less than 2 days before planned discharge Must be delivered even if beneficiary agrees with discharge Must use proper form considered invalid notice if not Beneficiary signs and dates; if refusal hospice annotates form and that serves as delivery date (beneficiary can still request ED) Alternate delivery methods allowable Telephone: date communication made is delivery date; obtain hard copy and keep in file Writing: certified mail; return receipt delivery is date of signature Fax or E mail (HIPAA privacy and security applies) Three Potential Financial Outcomes for Beneficiaries Following NOMNC Delivery NOMNC Delivered Beneficiary Files Appeal(s) Beneficiary Appeal(s) Upheld Beneficiary Has No Financial Liability for Care Provided after NOMNC DC Date Hospice Submits Claim to Medicare Hospice Decision Upheld Beneficiary Has Financial Liability for Each Day of Care after NOMNC DC Date Hospice Bills Beneficiary Beneficiary Does Not File Appeal Discharge as of Date on NOMNC All Rights Reserved 9
Important Points If hospice delivers NOMNC late, the beneficiary s right to ED still exists; financial protections extended to two days after valid delivery If beneficiary does not make request to QIO by noon the next day, financial protections are lost but still entitled to an ED Do not delay discharge and continue billing Medicare due to late NOMNC if it has been determined that beneficiary no longer eligible If care if provided after original discharge date, bill beneficiary for it The Most Vexing Question What is a hospice to do if medical director / hospice physician refuses to re certify the beneficiary? Questions All Rights Reserved 10
Question 1 If a patient is going to a consulting physician in the community or hospital (inpatient, 24 hour observation or ER visit) for a condition related to diagnosis but outside our plan of care, who should complete the ABN? Question 2 Patient is at the GIP level of care in the inpatient unit but no longer qualifies for the GIP level of care. Family refuses to take the patient home. Option 1: Level of care is changed to routine home care and we start billing for room and board. ABN? Option 2: Patient remains at GIP level of care. ABN? Question 3 Beneficiary experiences increase in pain but refuses further pain assessment by the hospice physician and IDG; indicates that he plans to go to a pain clinic. Hospice reviews hospice Medicare benefit with beneficiary and informs him that pain clinic would be outside plan of care and that he would be financially liable for the associated costs. Hospice also reviews the option of revocation. Beneficiary chooses to stay under current hospice election period and follow through with visit to the pain clinic. Who issues the ABN for the costs that will be incurred for pain clinic visit and subsequent interventions? All Rights Reserved 11
Question 4 Is the issuance of a mandatory ABN limited to the following rare circumstances: Hospice continues to provide care to a Medicare recipient that is no longer eligible for services, but wishes to be billed privately for care? Medicare patient refuses to discontinue GIP or CHC, so RHC services are billed to Medicare and the difference between the higher LOC and RHC is billed to the patient? Question 5 The final decision to decertify a patient that is no longer terminally ill is made at our weekly IDT meetings. Signatures are obtained within the preceding week on our discharge form and the NOMNC, using the IDT date as the effective date of discharge. Are we billing erroneously when the period of time between signature and IDT decision exceeds 2 days? If so, do other hospices make the decision to decertify outside the weekly IDT meeting? (Note: An NHPCO webinar done in 7/15 by Jennifer Kennedy states A 2 day minimum notice of discharge must be provided ) Question 6 How do you handle situations when the QIO says the patient should not be discharged but your medical director will not recertify them? All Rights Reserved 12
Actions of the Prudent Hospice Remain alert for the few situations in which an ABN or MOMNC may need to be issued Make sure that you have the correct up to date forms Provide training / resources to staff responsible for explaining the ABN and the NOMNC to beneficiaries and families. Don t rule out using business office staff member on the phone while IDG member in the home The QIOs operate 7 days a week; don t be scrambling trying to get information for the Detailed Explanation of Noncoverage on the weekend Document all situations thoroughly and carefully Regulatory Information 42 CFR 405 Subpart J Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges 405.1200 Notifying beneficiaries of provider service terminations. 405.1202 Expedited determination procedures. 405.1204 Expedited reconsiderations. Medicare Internet Only Claims Processing Manual Chapter 30, Financial Liability Protections Medicare Learning Network Advanced Beneficiary Notices https://www.cms.gov/outreach and Education/Medicare Learning Network MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf To Contact Us Susan Balfour 919 491 0699 Susan@HospiceFundamentals.com Roseanne Berry 480 650 5604 Roseanne@HospiceFundamentals.com Charlene Ross 602 740 0783 Charlene@HospiceFundamentals.com The information enclosed was current at the time it was presented. This presentation is intended to serve as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. All Rights Reserved 13
Medicare Discharge NO LONGER ELIGIBLE No less than two days prior to scheduled Discharge Day, issue NOMNC* (CMS 10123) Did beneficiary file an appeal with the QIO*? YES Issue by End of Business Day a. ABN* b. Detailed Explanation of Non-Coverage (CMS-10124) Did QIO* uphold hospice? NO Still requires hospice physician certification of terminal illness for care to continue. CONTINUE CARE YES NO Did the beneficiary YES file an appeal with the QIC*? Bill beneficiary for days of care provided since original discharge day NO Did the QIC* uphold hospice? NO DISCHARGE YES FOR MORE INFORMATION: visit www.hospicefundamentals.com or call us at 919-491-0699 2016 ALL RIGHTS RESERVED - HOSPICE FUNDAMENTALS. *ABN *NOMNC *QIO *QIC Advance Beneficiary Notice Notice of Medicare Non-Coverage Quality Improvement Organization Qualified Independent Contractor