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BILLING & COMPLIANCE: Persistence Is Key to ABN Success

When Medicare Is Shy, Break the Ice With Fail-Safe Forms
Since it's easy to drown in the extensive rules for advance beneficiary notices (ABNs), many providers end up with needless bills and compliance problems.
Following a few simple guidelines will keep you in the know about when you need a patient's John Hancock and when you don't.
Specify the Reason
What service do you think Medicare will deny, and more important, why do you think they won't pay? You must include this information on the ABN form, and in language the patient can understand. Just saying the service is "medically unnecessary" isn't enough, said Thomas Bartrum, JD, attorney at Baker Donelson Bearman & Caldwell in Nashville, Tenn., at a recent conference. List details about why you think they'll deny the service, and document multiple reasons if they're relevant. Without the highest possible specificity in your explanation, Medicare may consider your notice "routine," a boo-boo that invites trouble from CMS'Routine Notice Prohibition and may leave you with liability.
Use Proper Form
As of Jan. 1, 2003, form ABN-G, provided by CMS, should grace the hands of all patients for whom you expect Medicare denials. You'll need one copy for yourself, and one copy for the patient and make sure they are exactly the same, Bartrum says, because if your copy gets altered or the beneficiary doesn't have one, and the patient complains of inconsistency between the paper she signed and the one you're holding, fiscal intermediaries (FIs) will side with her, not you.
While ABN-G is a standardized form, you do have limited leeway to tailor it to your facility's needs. Three areas are open to customization: the header, the "Items or Services" box, and the "Because" box. Don't let the whole form exceed one page, but if you really need the space, it's OK to cheat by printing it on legal-sized paper to increase the amount of customizable room.
Timing Is Everything
CMS says you need to get the patient an ABN as soon as you suspect Medicare won't pay, but in realistic terms, Bartrum says, that means providing it before you furnish the service. The patient shouldn't be under any pressure to decide beyond the stress inherent in the current medical situation. Allowing him to make a rational, informed choice means delivering the ABN not only before you start the procedure but before you give him any physical preparation for it. His presence in the room of service an exam room, for instance doesn't count as "physical preparation," so doing the paperwork then is not creating a pressure situation.
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- Published on 2003-05-01