Are You Ready? The New Medicare Advance Beneficiary Notice (ABN)

  Medicare covers many products and services that are needed to manage chronic wounds. However, Medicare does not always cover the products for all indications, at the frequency that physician or the patient would like, etc. When a wound care clinic and/or practitioner believes that Medicare covers the product of service, but does not believe Medicare will cover it for a particular patient, that patient should be given an Advanced Beneficiary Notice (ABN). In addition, if a product or service, the practitioner is required to give the patient an ABN prior to treatment. If the patient is not given an ABN, and Medicare denies coverage of the product or service, the clinic and/or practitioner cannot collect payment from the patient.   To help readers understand the new Medicare ABN, I interviewed Donna Cartwright, MPH, RHIA, CCS, RAC, one of new editorial board members for Today’s Wound Clinic. Donna is a professional coder who brings over 27 years of medical coding expertise to the journal. She currently is the Senior Director of Reimbursement Services for Integra LifeSciences Corporation. Kathleen Schaum (KS):   Welcome to the editorial board of Today’s Wound Clinic. We are thrilled that you have agreed to share your reimbursement expertise with the readers. Today I would like you to educate our readers about the new ABN process. To begin, will you please begin by telling the readers the meaning of an ABN? Donna Cartwright (DC):   An Advanced Beneficiary Notice of Non-Coverage is a document that advises Medicare patients of services or products that may not be covered by Medicare prior to their treatment. It gives an estimate of costs by the practitioner of services that would be the patient’s responsibility, and gives the opportunity to the patient to decide whether they wish to have the treatment/item or not. KS: Who is required to issue an ABN? DC: ABNs must be used by providers, practitioners, and suppliers who are paid via Medicare Part B. KS: Why is it so important to fill out these forms correctly? DC: A provider is required to notify a beneficiary in advance when he or she believes that items or services will likely be denied as unnecessary or as constituting custodial care prior to the provision of the item or service. If this notice is not given, providers may not shift financial liability for items or services to beneficiaries should a claim for such services be denied by Medicare. Any provider that gives a defective notice may not claim that he or she did not know that Medicare would not make the payment as the issuance of a defective notice is clear evidence of knowledge. (If the person knew enough to write up a form, but did not take the time to fill it out properly, then this constitutes evidence that the practitioner had prior knowledge that the service was not covered.) KS: What types of events should trigger providers to issue ABNs? DC: Providers should remember three terms in relation to ABNs: initiation, reduction, and termination.   Initiation is the beginning of a new patient encounter, start of a plan of care, or the beginning of treatment. If a provider believes that certain otherwise covered items or services will not be covered an ABN must be issued prior to the provision of non-covered care. For example: if the provider believes that Medicare will deem that the product or service is not reasonable and necessary,   Reduction is when a component of care, such as frequency or duration, is decreased. The reduction in treatment would require an ABN. For example: a patient wants 5 days of physical therapy a week, but the provider believes it can be accomplished in 3 days.   Termination is a discontinuation of certain items or services. Termination is discontinuation of a service or item due to a lack of medical necessity. For example: The provider thinks therapy is no longer reasonable and necessary, but the patient wants to continue. KS: What are the mandatory uses for an ABN by a wound care provider? DC: Wound care providers must issue ABNs under these circumstances:     A. Services or items are considered unreasonable and unnecessary.     B. Medical Equipment and Supplies that will exceed the number of items that will be covered by Medicare.     C. Medical Equipment and Supplies are denied in advance. For example: if a particular dressing is not covered, an ABN is required. KS: What is the patient’s liability if they were provided a properly executed ABN and they agreed to pay? DC: The patient can be held liable for the bill for the items on the form. If the document is not completed properly or adequate notice was not given, the patient is relieved from liability. KS: What is considered adequate notice? DC: The ABN should be executed prior to the provision of the item or service. KS: Can providers collect money from the patient for non-covered items or services immediately after the ABN is signed? DC: Yes, providers may collect payment immediately after the ABN is signed unless some other applicable Medicare policy, state, or local law prohibits collection of payment in advance of the Medicare payment determination. KS: Once a patient signs an ABN, how long is it effective? DC: A new ABN must be signed each time the patient receives a product or service, even if the patient signed an ABN for the same product or service in the past. KS: What happens if the patient changes his/her mind? DC: The patient must request to change the original ABN and provide a clear indication of his/her new option selection. KS: I understand that a new ABN form is about to be implemented. What forms will be replaced and what is the new form? DC: The following forms will no longer be valid and can be viewed on Exhibit A:     1. Advance Beneficiary Notice ABN-G     2. Advanced Beneficiary Notice ABN-L   The new form is CMS-R-131 and is entitled Advanced Beneficiary Notice of Noncoverage. See Exhibit B. KS: Where can the readers find information regarding ABN’s on the CMS web site? DC: This information can be found in several places:     1. On the Beneficiary Notice Initiative Web page at www.cms.hhs.gov/bni     2. In the CMS Medicare Claims Processing Manual Chapter 30, there is a Transmittal 1587, change request 6136 dated September 5, 2008 that provides a detailed description of the revised form and the requirements associated with its use.     3. Via a provider education article available at https:www.cms.hhs.gov/MLNMattersArticles/. KS: Are the new forms available in languages other than English? DC: Yes. A Spanish version is available on www.cms.hhs.gov/bni KS: Exactly when is the effective date for the new ABN form? DC: The new ABN form Advance Beneficiary Notice of Noncoverage CMS-R-131 will be effective on March 1, 2009. KS: Medicare normally has a transition period when they create new forms. Was there a transition period for the new ABN form? DC: CMS allowed a 6-month transition period from the date of issuance (September 5, 2008) of the instructions for the mandatory use of the revised ABN. Therefore, these forms must be implemented by March 1, 2009. KS: What are the major new items of the new ABN form? DC: There is a mandatory field for cost estimates of the items/services that may not be covered. In addition, the beneficiary options are new. The beneficiaries can choose to do one of 3 things:     1. Have the service or supply and pay for it right away, but ask the provider to bill Medicare for an official determination on payment. If Medicare does not pay, the beneficiary understands that they are responsible for payment, but can appeal to Medicare. If Medicare pays, the provider will refund any payments made, less co-pays or deductibles.     2. Have the service or supply but do not bill Medicare. The beneficiary will be asked to pay for the service because they will now be responsible. In addition, beneficiaries may not appeal to Medicare because Medicare will not be billed.     3. Not to have the service. Therefore, the beneficiary is responsible for payment. KS: What information should providers place in the blank item D on the new ABN form? DC: Providers should list the item, service, laboratory test, test, procedure, care, supply, or equipment. For repetitive or continuous non-covered care, specify the frequency or duration of the service or item. General descriptions of specifically grouped supplies are permitted. For example, “wound care supplies” would be a sufficient description, and an itemized list is generally not required. KS: What information should providers place in item E “Reason Medicare May Not Pay”? DC: Providers should explain, in a language that patients will understand, ‘why’ Medicare may not pay for an item or service. Three commonly used reasons for noncoverage are:     1. Medicare does not pay for this test for the condition.     2. Medicare does not pay for this test as often as this.     3. Medicare does not pay for experimental or research use tests. KS: How should providers determine the estimated cost for item F? DC: Providers should make a good faith effort to provide a reasonable estimate for all items or services listed in section D. The estimate generally should be within $100.00 or 25% of the actual costs, which ever is greater. However, an estimate that exceeds the cost substantially would be acceptable since the beneficiary would not be harmed if costs were less than predicted. KS: If a practitioner is reported as not complying with the ABN of Non-Coverage, and claims that they had no prior knowledge that the claim might be denied, what might Medicare look at to determine if the practitioner had prior knowledge? DC: A provider is responsible for properly identifying to patients the services or items that may not be covered by Medicare using all reasonable efforts. Medicare could review previous claims submitted by the practitioner. For example, if the previous claims were denied, that would demonstrate that the provider had prior knowledge that the service was denied. KS: Can providers modify the ABN form? DC: The ABN form may be customized with some pre-printed information, such as the name and address of the provider, and preprinting of known treatment scenarios and costs that may not be covered in order to increase office efficiency. Providers may not pre-select the beneficiary options, which must be completed by the beneficiary. If you choose to customize the form, you should remove letters A-J on the sample form prior to creating your own template. Nothing Substantive may be changed on the form.   Summary: If wound clinics and practitioners do not establish a process to provide ABNs to patients who come in for a product or service, that Medicare covers but will most likely not be covered for that patient, they may lose thousands of dollars each year. As Ms. Cartwright explained, a good ABN process begins by using the correct ABN form. Then wound clinics and practitioners need to identify products or services that were: 1) frequently denied because they were unreasonable and unnecessary; 2) provided more frequently than allowed; 3) considered preventive services; 4) are considered as screening examinations, etc. The clinics and practitioners should also establish reminders that will alert them when a product or service requests an ABN. For example: Flag the products or services in your electronic health record, in your super bills/charge sheets, on your Charge Description Master, etc. For convenience and to serve as a reminder, make ABNs accessible by placing them in registration packets, in exam/treatment rooms, etc. Finally, and most importantly, educate all staff and practitioners about the value of using ABNs and how to use the new ABN that will be effective on March 1, 2009.   To view the Deleted ABN Forms and to view the new form, please visit https://www.todayswoundclinic.com/abn-forms. Kathleen D. Schaum, MS, is President of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.