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Advance Beneficiary Notices [ABNs]

Understanding “Medical Necessity” Billing

By Patricia A. Trites; PhD, MPA, CHBC, CMP™ (Hon)

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Some doctors, healthcare executives and/or their insurance or billing advisors do not realize that just because an item or service is not “medically necessary” for billing purposes (in other words, a payable diagnosis); that same item or service may be perfectly necessary for the health or welfare of the patient. 

This is where Advance Beneficiary Notices (ABNs) can save the medical practice or healthcare organization much time and money in the billing process. 

Defining the ABN

Advance Beneficiary Notices [ABNs] are statements that are given to the patient to read and sign whenever a provider believes that the item or service may not be covered (paid) by Medicare.

Reasons for Use

This may occur when there are a limited number of services that can be performed in a specific time frame, such as, mammography, PSA, colonoscopy, etc.

It can also be used when a patient insists on a specific treatment or test, even when the physician believes the service is unwarranted or unnecessary, but understands that failing to provide the service may put him/her at risk under professional liability standards.

Risk Transfer Mechanism 

When an Advance Beneficiary Notice has been signed by the patient, it removes the risk of non-payment from the provider.But, Advance Beneficiary Notices cannot be given to every patient or for all procedures or services. 

Assessment 

There must be a reasonable expectation that payment will be denied because there is a lack of medical necessity (for billing/ payment).   To access complete instructions for the use of ABNs and copies of the specific form that must be used for Medicare patients, go to https://www.cms.gov/

Conclusion:

What has been your experience with ABNs, as a medical provider and/or healthcare executive? 

  Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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2 Responses

  1. New ABN Forms

    Did you know that a new ABN form was released in March 2008? The new form is listed as “CMS-R-131 (03-08)”. All providers must use the new form as of September 1, 2008. However, providers can also use the new form now. The new form includes a mandatory field in which the provider indicates the estimated cost of the services. It also includes a field which can function as the “Notice of Exclusion from Medicare Benefits.”

    -Ann

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  2. ABN Form Revised
    [Revised Form Mandatory Use Date]

    The Centers for Medicare & Medicaid Services (CMS) just announced a revision to the Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, which is issued in circumstances when Medicare is expected to be denied.

    The mandatory use of the revised form was changed from September to November 1, 2011, to allow extra time for providers and suppliers with pre-printed stockpiles of the previous ABNs to exhaust their supplies.

    http://www.cms.gov/BNI/02_ABN.asp

    Zeke

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