What Providers Need To Know About ABNs

Providers may have heard that they are required to provide in certain instances Medicare beneficiaries with an Advanced Beneficiary Notice of NonCoverage (ABN) but the specifics of the requirements may not be known to everyone.

What’s an ABN?

Physicians are required to provide an ABN, Form CMS-R-131, before they provide services that they know or believe Medicare does not consider reasonable and necessary. In other words, when Medicare payment is expected to be denied, a healthcare provider should give an ABN to the patient.

What are the requirements for filling out an ABN?

A properly executed ABN acknowledges that coverage is uncertain or yet to be determined and stipulates that patient promises to pay the bill if Medicare does not. Patients who are not notified before they received such services are not responsible for payment as the objective of the form is to give the patient sufficient information to allow an informed choice of whether to pay for services or refuse treatment.

According to the  Center for Medicare and Medicaid Services (CMS) instruction manual accompanying the form, an ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the provider may deliver the ABN.

CMS instructional manual provides that ABNs are never required in emergency or urgent care situations.

Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. When filling out information about Medicare beneficiary on an ABN, an internal filing number created by the provider, such as a medical record number, may be used. Medicare numbers (HICNs) or Social Security numbers,however, must not appear on the ABN.

In all cases, CMS advises that the provider retain the original notice on file.

Both, CMS and the Office of Inspector General, which is an independent oversight agency within the U.S. Department of Health and Human Services, warn against providers engaging in routine use of ABNs because the ABN must state the specific reason the provider anticipates the specific service will not be covered. For example, an accepted reason could include one of the following: 1) “Medicare does not pay for this test for your condition;” 2) “Medicare does not pay for this test as often as this (denied as too frequent);” or 3) “Medicare does not pay for experimental or research use tests.”

When providing an ABN to patients, CMS requires that providers use the latest form as they are updated by the agency from time to time. The latest ABNs and an instruction manual on how to fill out an ABN, which providers should read to become familiar with all the CMS requirements for ABNs, is on the CMS website.