Confusion Reigns: Advance Beneficiary Notice of Non-coverage

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Just as wound and ulcer management professionals never know what to expect when they remove the dressing from a wound/ulcer, reimbursement consultants never know what questions people will ask them when the phone rings or when they receive an email. For the past month, this author/consultant has been receiving calls and emails from professionals throughout the country. Somehow misinformation about the use of an advanced beneficiary notice (ABN) of non-coverage is spreading like wildfire. When the first professional called, this author/consultant just thought this was a one-off issue. However, after responding to 100+ inquiries about ABNs this month, it is obvious that ABNs are a “hot topic” right now.

Wound/ulcer management professionals, providers, and suppliers are trying to use all available resources to offset the claim denials and post-payment audits that they are experiencing. The ABN is a great tool to use when Medicare normally covers a service, procedure, or product, but does not cover it for a specific reason for an individual Medicare beneficiary. In those circumstances, if the beneficiary determines that they need and are willing to pay for this item, selects the appropriate option on the ABN, and signs the ABN, the financial liability then rests with the beneficiary. However, the professionals, providers, and suppliers must use the correct form, must carefully follow the ABN instructions, and must report the correct ABN modifiers on claims submitted to Medicare. The current ABN form, which must be used, and the instructions for use are available at this link.

To learn from the misinformation that was reported this month, the Tables below depict the most common scenarios reported, answers to the ABN inquiries, and appropriate uses for ABNs.
 
Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.