Clearing up the Confusion: The Dreaded ABN

Proper use of the Medicare’s Advanced Beneficiary Notice (ABN)

At KMC University we are frequently asked about Medicare’s Advanced Beneficiary Notice (ABN). There are many aspects to the ABN such as Mandatory and Voluntary; Participating and Non-Participating Providers; when to use each of them correctly; and how to explain them to the patients. All of this can leave providers and staff a bit befuddled – to say the least.

So, lets clarify

The ABN is an Original Medicare document, and it should not be used with other carriers including Medicare Advantage or other types of Medicare replacement plans. If you are in need of an ABN for a Medicare Advantage plan, you should contact them directly or consult the Medical Review Policy.

The Mandatory ABN is the one that should be used appropriately and compliantly in your office. In 2018, Medicare made a distinction to this form for Participating Providers and Non-Participating Providers.

Both Participating and Non-Participating Providers would use this form for the same situation. It should only be used when a Medicare Beneficiary is transitioning from Active Care to Maintenance Care. The ABN must be signed by the beneficiary prior to the first Maintenance treatment.

Think of it this way: The Mandatory ABN is used appropriately to notify the beneficiary in advance that services that were previously covered will no longer be covered; i.e. Maintenance.

• The beneficiary’s name must appear at both the top and bottom of the ABN form exactly as it does on the Medicare ID card.
• The Medicare ID number must NOT be placed on the ABN form.
• The only services listed on this form will be the CMT codes (98940-98942).

The beneficiary must choose between the three options available on the form. This choice can not be solicited, coerced or delegated by a staff member or the provider. Patients should be presented the options; given the opportunity to ask questions if needed; and allowed to choose the best option for themselves.

• Once the form is complete, the beneficiary must be given a copy of the document.
• This form is good for 1 calendar year if the patient remains on maintenance for that time frame.
• If the patient should go back into an active episode of care, a new ABN would need to be signed when the patient transitions back again into maintenance.

New in 2018

Medicare recently stated that a modification to the Mandatory ABN was necessary when the provider was of the Non-Par status AND NOT ACCEPTING ASSIGNMENT. If you fall into this category, you will strike through the last sentence in the Option 1 paragraph with a single line. It should appear like this:

If Medicare does pay, you will refund any payments I made to you, less co-pays, or deductibles.

This strike through can be done on an original document prior to printing or can be hand-penned on an already printed ABN. This sentence must only have the strike through and not be completely concealed. It does not need to be initialed by the beneficiary.

When the strike through appears on the ABN in Option 1, the following statement must also appear in (H) area:

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”” (10-point font or larger or hand written)

The Voluntary ABN

The Voluntary ABN is KMC University’s language to describe using Medicare’s official ABN document for “non-mandatory” uses. Medicare doesn’t require the patient to sign an ABN form to acknowledge services never covered by Medicare. In Chiropractic, this includes providing advance notice for costs for services like exams, x-rays, and therapies. However, using their official form for voluntary use can cause confusion. Patients often get the two forms confused because they look alike. The guidelines indicate that when using the official form, you may not ask for a signature or ask the patient to select an option. For these reasons, we recommend that you never use Medicare’s official ABN form for voluntary advance notice. Instead, place the information on your office letterhead and get signed acknowledgement, and provide a copy. That way, it stands out to the patients, and they can sign the document for both authorization and authentication.

To better understand proper use of the ABN form for Medicare or other Medicare, compliance, and reimbursement issues, join KMC University today. Each Library member is assigned their personal Account Manager for assistance and guidance in the Library. Your KMC University Library materials, along with your Account Manager will help to ensure that you and your practice have the most current information available!