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By Jackie Birmingham, RN, BSN, MS, CMAC.
A Medicare beneficiary (or authorized representative) who has been given an Advance Beneficiary Notice of Noncoverage (ABN) may elect to receive the item or service anyway. In this case, the beneficiary should indicate that he or she is willing to be personally and fully responsible for payment by marking options 1 or 2 in box G on the ABN form. This new version of the ABN is used before services are rendered (as the name implies) and it may be given by outpatient department staff.
Here are some more tips regarding filling out the ABN:
- Option 1 indicates the beneficiary or representative will pay for the service out of pocket, but the hospital will also bill Medicare to see whether Medicare will pay for the item or service. If Medicare does not pay, the patient has the opportunity to appeal, but there is no guarantee Medicare will pay for the item or service.
- Option 2 indicates the individual accepts full financial responsibility for the item or service. Medicare will not be billed, and the beneficiary cannot appeal. This option requires that the patient be informed of the cost of the service prior to receiving the service.
- When a beneficiary decides to decline an item or service, he or she should indicate this by marking option 3 in box G on the ABN form. Counseling the patient on this decision and documenting the discussion is important. The service has been ordered based on the patient’s physician’s advice, and if the patient declines the item or service, it is important to be sure that he or she is fully informed of the consequences of the decision.
- The beneficiary cannot refuse to sign the ABN and still demand the item or service.
- If a beneficiary refuses to sign a properly executed ABN, the notifier should consider not furnishing the item or service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
- Additionally, the notifier may annotate the ABN, and have the annotation witnessed, indicating the circumstances and persons involved.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
Medicare has been going through a number of transitions recently. One of these transitions relates to the appropriate form of notice when certain providers, including hospitals and physicians, believe that the outpatient services ordered by the patient’s physician fall under the limitation on liability provisions of the Social Security Act. Under these provisions, the provider must provide advance written notice to the beneficiary (or his or her representative) prior to the performance of the services in order to be able to bill the beneficiary for those services if Medicare denies coverage.
Limitation on liability is likely to arise in the outpatient setting when the services ordered fail to meet Medicare coverage criteria for one of the following reasons:
- They fail to meet Medicare’s medical necessity guidelines;
- They are screening services that are provided more frequently than Medicare provides a benefit for; or
- They are custodial services.
In order to successfully shift financial liability to the patient, the provider must provide a prescribed form of notice prior to the performance of the services. Medicare is currently phasing out the prior prescribed forms (ABN-G and ABN-L), which continue to be effective through February 28, 2009. On and after March 1, 2009, however, providers must use the revised ABN form (CMS-R-131) in order for the advance notice to be effective when limitation on liability applies to outpatient services.
The revised form initially became effective for services provided on and after March 3, 2008, which gave providers a year to transition to the revised form. There are a number of technical requirements set out in the Medicare Claims Processing Manual, Chapter 30, that must be met if the ABN is to be effective. Most of the requirements that apply to the revised form are very similar to those that applied to the prior forms.
In September, 2008, Medicare issued Medicare Claims Processing Manual Transmittal 1587, which contained specific, updated instructions on completion and use of the revised ABN. The most significant change is the requirement that “Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed . . .” on the ABN. Nevertheless, Medicare permits a great deal of flexibility in meeting this standard. For example, so long as the estimate is within $100 or 25% of the actual costs, whichever is greater, the notifier will be considered compliant.
With just a month left during the ABN transition period, it is essential that providers assure that they are prepared to be fully compliant with the new requirements, including a good faith cost estimate, as set out in the updated sections in Chapter 30 of the Medicare Claims Processing Manual.
York (ME) Hospital finds bedside registration in the emergency department one of the most effective tools to ensure an accurate and compliant patient claim.
Pat Finnemore, CHAA, who works on the patient access team at the 11-bed ED facility, says bedside registration in the ED:
- Increases efficiency of workload for registrars
- Opens strong lines of communication between clinical and access teams
- Provides convenience for patients who do not want to be shuffled from place to place.
“We have not found this process to be more difficult at all,” Finnemore says. “We have an excellent working relationship with the clinical staff. Patients also like not being shuffled around. They can get in and get comfortable.”
Advance Directive forms, to be completed by patients in case they are unable to make medical decisions for themselves, most often are presented by patient access staff members.
But any lack of communication among access, nursing, and case management staff members can lead to unnecessary confusion and headaches during compliance checks. Mandatory requirements from CMS, including the Fair Patient Billing Act, are on the minds of access managers lately. The goal is to comply and present Advance Directive forms in the most patient-friendly, transparent way.
Here are two tips from one patient access manager:
Just ask. The responsibility lies with patient access staff members to ask whether patients have or need a form. “My staff are informed during training on how to ask,” says Vonda DeLorenzo, patient registration supervisor at Central Michigan Community Hospital in Mt. Pleasant. “For example: ‘I see that you don’t have an Advanced Directive for Healthcare. Would you like a copy?’ ”
Explain it like a “living will.” What if a patient asks about the form? DeLorenzo says they explain it as if it were a “living will,” although Michigan doesn’t recognize that term. “It is where you set up in advance your medical wishes should you become incapacitated and are unable to speak for yourself regarding your medical care,” DeLorenzo adds. “You usually appoint an advocate who will act on your behalf, and [he or she has] to agree to act on your behalf. We try to keep it short and sweet and not spend too much time on it. Very few people are interested. You always get the one who wants to know if they are going to die today.”
In light of the significant number of changes to the revised ABN (including the related revisions to Chapter 30, Section 50 of the Medicare Claims Processing Manual) and the potential consequences for failure to provide advance notification when limitation on liability applies, healthcare providers are encouraged to do the following:
- Form a cross-disciplinary team with related responsibilities to transition to the revised ABN
- Review the revised ABN form
- Review the ABN FAQs and Form Instructions, as well as the revised provisions in Chapter 30, Section 50 in the Medicare Claims Processing Manual
- Review the existing Forms ABN-G and ABN-L, as well as the current ABN notification process
- Identify any outstanding questions that require clarification before proceeding
- Identify key changes that need to be implemented in order to be able to transition to the revised ABN by March 1, 2009
- Create a transition action plan, with timetables and accountability by departments/key individuals
- Implement the action plan, with ongoing monitoring and evaluation to determine whether target dates and plan objectives are being met
Editor’s note: Judith L. Kares, JD, CPC, authored this submission. She is an instructor for HCPro’s Medicare Boot Camp – Hospital Version. She is a lawyer and consultant who provides legal services and related healthcare compliance services to a wide variety of clients, including hospitals, health systems, HMOs, third party payers, physician practices and other healthcare entities. Visit www.hcprobootcamps.com to learn more.
Patient access departments play an important role in protecting the hospital’s reimbursement for cases that are reviewed by RACs.
Use the holiday season to provide a review session for all access registrars by reviewing a sample of physician orders to ensure that the physician specifically states “admit as inpatient” or “admit for observation services.”
Do not assume that the word “admit” means an admission to an inpatient bed. For orders written for observation services, the orders must be dated, timed, and signed, and include a clinical reason for being admitted to observation. If the reason is lacking, call the physician’s office for this information. If the clinical reason is not clear, refer the order to your Utilization Review/Case Management liaison.
Editor’s note: These tips were submitted by Rose T. Dunn, RHIA, CPA, FACHE chief operating officer of First Class Solutions, Inc., in Maryland Heights, MO.
As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:
- The services fail to meet Medicare’s medical necessity guidelines
- The services are screening services that are provided more frequently than Medicare provides a benefit for
- The services are custodial in nature
Want to know how your peers do with their registration accuracy rates? Want to know if their numbers are better than they were 18 months ago?
That is why we prepared this eight-page benchmarking report. Your revenue cycle department is only as good as your patient access team. And it all begins with accuracy on the front end.
To read the report, please click here.
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