Q: What is an Advance Beneficiary Notice?

An ABN is a written notice you must give to a Medicare beneficiary when you believe that Medicare probably or certainly will not pay for some or all items or services because they are not medically necessary.

You must present the ABN before services or items are provided to inform the beneficiary that Medicare will probably not pay for the services or items at this particular encounter. The ABN informs the beneficiary that they may have to pay for the service or item out of pocket or through other insurance. The ABN must include an explanation in understandable terms as to why you believe the service or item will be denied. This process allows the beneficiary to make an informed decision about whether or not to accept the service or item.

Center for Medicare & Medicaid Services Form CMS-R-131 is the new Advance Beneficiary Notice. As of Oct. 1, 2002, every provider should be using this form. You can obtain it at the CMS web page at http://cms.hhs.gov/ medicare/bni/. The ABN form is also available in Spanish.

ABNs are not required for items or services that are excluded by statute, such as refractions, cosmetic surgery, and eyeglasses or contact lenses for pseudophakic patients who have utilized their benefit. You may choose to notify patients that these services are never covered, but do not use the Medicare ABN form to do so.

The same form is used for physician services, surgery centers and optical dispensaries. It is required for both assigned and non-assigned claims as well as for optical dispensaries that are not Medicare providers. It is designed for use with Medicare beneficiaries only and includes patients who are dually eligible for Medicare and Medicaid. You may use one ABN for an extended course of treatment if all items and services are itemized. It is valid for one year. However, a new ABN is required if additional items or services not listed on the original ABN are provided.

Q: Can I develop a generic ABN?

No. A generic ABN would be nothing more than a signed statement by the beneficiary stating that if Medicare denies the service or item, the beneficiary agrees to pay. Because a generic ABN does not provide specific information about the service or item or provide a reason for anticipated denial, it is not considered acceptable evidence of advance beneficiary notification.

You may modify the form, but it must be readable and understandable for the beneficiary. A font size of 10 or 12 point is recommended and must be a readable font, i.e., Arial or Arial Narrow. Dark blue or black ink on white paper is also recommended and shading is prohibited. The form must be one page, single sided.

The header should contain your name, address, and telephone number. You may also add your logo and other information if desired.

You may customize the "Items or Services" and "Because" boxes with pre-printed lists of common items, services and denial reasons. The items or services and the reasons for possible denial must be described in enough detail that the patient understands what's being provided and why it's likely to be denied.

Q: If a patient signs an ABN, am I obligated to file a claim?

Yes. Medicare has published a requirement that claims be filed whenever an ABN is obtained (PM AB-02-114). Submit your claim with modifier GA appended to the appropriate CPT or HCPCS code. The mandatory claims filing requirement was effective Oct. 1, 2002.

Before asking the patient to sign the form, certain portions of the form must be completed. They include: the patient's name; the patient's Medicare number; the proposed items or services; and the reason denial is expected. The estimated cost field is optional. The patient must personally choose between Option 1 and Option 2. Option 1 indicates the patient wants to receive the items or services. Option 2 indicates the patient has decided not to receive the items or services.

You must give the patient a legible copy of the form. The original ABN must be placed in the patient's permanent medical record.

If a patient is unable to sign, an authorized representative may sign instead. The patient or representative must be able to understand the form and make an informed decision about accepting financial responsibility. The responsible party cannot be you or someone in your practice.

Q: What if Medicare pays, even though I have a signed ABN and know the claim should be denied?

Using modifier GA on a claim does not automatically cause a denial. It is advisable to discuss this with patients in advance. If Medicare pays and you are certain that they should not have paid, explain to the patient that Medicare paid the claim in error. Refund Medicare promptly.

If Medicare denies the claim, but you neglect to get an ABN signed by the patient, you may not collect payment from the patient. If you have already done so, you must refund any payment received within 30 days unless you contest Medicare's denial. If you lose your appeal, you have 15 days from the final determination to refund the patient. For additional information, visit http://cms.hhs.gov/medlearn/ refabn.asp. 

Ms. McCune is senior consultant for Corcoran Consulting Group. Contact her at dmccune@corcoranccg.com.