By: Zach Simpson
Does your office treat Medicare or Medicaid beneficiaries? If so, this article is vital to you and your staff. The first question that I want all of you to ask yourself is if your practice treats Medicare or Medicaid beneficiaries do you know what an ABN is, and why they are vital for your practice? The acronym ABN stands for Advance Beneficiary Notice of Non-coverage. ABNs safeguard your practice’s right to collect on non-covered services (other than statutorily excluded services) from patients who have Medicare or Medicaid. Multiple organizations I have worked with throughout my career had never been informed about ABNs or had never been properly educated on how utilize them. This article is intended to provide you and your practice with the most recent information regarding the renewed ABN form that became mandatory for use on January 1, 2021.
As of January 1, 2021, a new Fee-for-Service Advanced Beneficiary Notification of Non-coverage became effective until it expires on June 30, 2023. In the event that your practice has been utilizing the same ABN forms for years then listen up.
Why Do I Need To Utilize A New ABN Form?
You may ask yourself the question above, and wonder why your practice would need to update the ABN template that more than likely has been utilized for years in addition to task of having to train your staff on a new form. The answer is quite simple. There have been changes to the ABN, and in the event the most current version is not utilized, your ABNs may be viewed as invalid. For example, guidelines for Dual Eligible Beneficiaries, meaning patients that have both Medicare and Medicaid coverage have been added to the ABN form instructions. The reason that additional guidelines were included were to ensure that the current ABN complied with the billing prohibitions for patients in the Qualified Medicare Beneficiary (QMB) program. A QMB program helps pay the premiums, deductibles, coinsurance and copayments for both Part A and Part B or both.
New Special Instructions
For any patients enrolled in a QMB Program it is important to remember that they cannot be charged for Medicare cost sharing for covered Parts A and B services, nor are they allowed to elect to pay Medicare cost sharing. Due to this, special instructions provided by CMS apply when a provider issues an ABN to a Dual Eligible Beneficiary:
In order for a claim to be submitted for Medicare adjudication the Dually Eligible Beneficiaries must be instructed to check Option Box 1 on the ABN per the new CMS instructions that can be found via the link at the end of this article.
When dealing with a Dually Eligible Beneficiary, CMS requires providers to strike through the language in Option Box 1 as provided below, and ensure that the language is still legible rather than being completely blacked out when striking through such language:
OPTION 1. I want the D. (service or supply) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.
Be aware that per CMS a provider can only charge a patient under the following circumstances only after both Medicare and Medicaid adjudicate the claim:
- The ABN could allow the provider to shift financial liability to the patient per Medicare policy if the patient has QMB coverage without full Medicaid coverage
- Subject to any state laws that limit beneficiary liability an ABN could allow a provider to shift financial liability to the patient per Medicare policy if the patient has full Medicaid coverage Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid)
Be aware that these instructions should only be utilized when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances.
For a copy of the most recent complete ABN form instructions issued by CMS please click here.
For a copy of the most recent ABN form template issued by CMS please follow the link below. The needed forms can be found on this page underneath Downloads.
