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Healthcare providers must be aware of future Medicare modifications on the ABN

The Advance Beneficiary Notice (ABN) will have modifications effective October 14th that healthcare providers need to be aware of to ensure their payments

There will be some changes to the Advance Beneficiary Notice of Noncoverage (ABN) section in the Medicare Claims Processing Manual. The Centers for Medicare and Medicaid Services (CMS) announced those changes will be effective in October 2021.

It is important that all healthcare providers are aware of these changes. This can help doctors and providers to avoid any payment issues and ensure they are getting paid for their work.

What is the ABN?

According to the CMS, the Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued to the patients by healthcare providers.

There are various healthcare providers required to use this form including independent laboratories, home health agencies and hospices, physicians, nonphysicians practitioners, and suppliers to Original Medicare (fee for service – FFS) beneficiaries in situations where Medicare payment is expected to be denied.

The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30.

This form helps patients decide whether to accept financial responsibility for services or supplies that Medicare may not cover.

Not issuing the ABN prior to providing supplies or rendering selected services is a risk that the provider/supplier may not be paid. By signing the ABN, the patient agrees to accept liability to pay for these should Medicare deny coverage.

If the provider fails to issue ABN prior to service patient will not be liable for denied services resulting in nonpayment to the provider/supplier.

To be valid, it is important that the ABN form is properly completed and executed by the patient. Otherwise, the provider will not be allowed to bill the patient. The requirements are outlined in the Medicare Claims Proccesing Manual referenced above.

What are these changes effective October 14th, 2021?

Some of the key revisions of the ABN section in the Medicare Claims Processing Manual include:

General notice preparation requirements for the ABN

Period of effectiveness of the ABN for repetitive or continuous non-covered care

According to the CMS, an ABN remains effective after valid delivery so long as there has been no change in the following:

  • Care from what is described on the original ABN.
  • The beneficiary´s health status which would require a change in the subsequent treatment for the non-covered condition; and/or
  • The Medicare coverage guidelines for the items or services in question (i.e., updates or changes to the policy of an item or service).

A new ABN must be issued if any of the above changes during the course of the treatment.

How the Financial Liability Protections (FLP) provisions apply to dually eligible individuals (a Qualified Medicare Beneficiary (QMB) Program or Medicaid coverage)

Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication. CMS did some changes on this option.

For future ABNs, this option must be shown as:

OPTION 1. I want the (D)_________listed above. I want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN).

These edits are required because the provider cannot bill the dual eligible beneficiary when the ABN is not furnished.

Once the claim is adjudicated by both Medicare and Medicaid, providers may only charge the patient in the following circumstances:

  • If the beneficiary has QMB coverage without full Medicaid coverage, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy.
  • If the beneficiary has full Medicaid coverage and Medicaid denies the claim, the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary liability.

These instructions should only be used when the ABN is used to transfer potential financial liability to the beneficiary and not in voluntary instances. More information about dual eligible beneficiaries can be found at Dually Eligible Beneficiaries under Medicare and Medicaid

Information on ambulance transports

Regarding emergencies or urgent situations, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress. ABN usage is the ER may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.

In cases of non-emergent or non-urgent ambulance transport, if the provider wants to transfer liability to the beneficiary, the ABN is mandatory if all the following 3 criteria are met:

ABN issuance is mandatory only when a beneficiary’s covered ambulance transport is modified to a level that is not medically reasonable and necessary and will incur additional costs.

Events that cause home health agencies to issue ABNs

When a beneficiary who has been receiving hospice care is no longer terminally ill and the beneficiary is going to be discharged from hospice, the hospice may be required to issue the Notice of Medicare Non-coverage (NOMNC), CMS 10123.

If upon discharge the patient wants to continue receiving hospice care that will not be covered by Medicare, the hospice would issue an ABN to the beneficiary in order to transfer liability for the non-covered care to the beneficiary.

If no further hospice services are provided after discharge, ABN issuance would not be required.

ABNs are not required for Hospice Services in situations such as revocations, respite care beyond five consecutive days, transfers, failure to meet the face-to-face requirement and room and board costs for nursing facility residents.

If you want to know more about these changes or how Health Prime can help you stay on top of your medical practice and get paid for your work, feel free to reach out to us at businessdevelopment@hpiinc.com.

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