What is the purpose of the Medicare ABN form?
An ABN is a way for a Medicare beneficiary to make an informed decision about receiving items and services that are usually covered by Medicare, but may not be expected to be paid in a specific instance for certain reasons, such as lack of medical necessity. The ABN protects both the patient and doctor from unexpected financial liability resulting from charges for services Medicare does not deem reasonable and medically necessary; Medicare does not pay for:
- Care that is not reasonable or medically necessary (i.e., maintenance care), once the patient has reached maximum improvement
- Treatment that exceeds the number of adjustments established as a screen by the carrier as reasonable for treatment of the patient’s diagnosis (or condition)
When do I use the Medicare ABN form?
A patient must sign an ABN when you are recommending Medicare covered services (spinal adjustments) that you believe Medicare won’t cover, but that you feel are warranted and necessary for the patient’s condition, even if maintenance care. The patients must sign the ABN to move forward with care, acknowledging their understanding that Medicare likely will not cover the cost of the spinal adjustments and signing off on one of three options:
- The patient wants the maintenance care and wants you to bill Medicare for it, even though it probably won’t be covered. This is the only way the claim could be appealed, if necessary.
- The patient wants the care and does not want you to bill Medicare for it. They don't have an interest in appealing, as they understand the nature of the maintenence care.
- The patient is choosing not to follow the recommended maintenance care, and it's ideal to get that in writing. Do your best to get the ABN signed, but if they refuse, simply note the chart.
When is an ABN not required?
An ABN is not required for chiropractic care that is never covered under Medicare, including:
- Exams, x-rays, and laboratory tests
- Physical therapy, adjustments to areas other than the spine, and acupuncture
- Personal comfort or convenience items
Also included are Durable Medical Equipment (DME) items if the doctor is not enrolled as a DME provider in the Medicare program.
For simplicity, we divide ABNs into two categories...Mandatory or Voluntary. Read on to better understand this distinction.
What is a Mandatory ABN?
Medicare policy dictates that an ABN is required (mandatory) only for covered services (for DCs, that's spinal manipulation), that may not be covered on this visit.
So, if you are treating a patient and feel that the treatment no longer meets the medical necessity requirements outlined by Medicare, then you MUST notify the patient. You will then administer the Mandatory ABN notifying the patient that they will be receiving maintenance care which is NOT covered by Medicare. They will then decide if they want it or not. If so, they acknoweldge financial responsibility for the service.
All other services (such as exams, x-rays, therapies, etc) are not considered statutorily non-covered, or excluded from Medicare, and as a result an ABN is not required (mandatory).
What about a Voluntary ABN?
It's good business practice to notify patients of services that may not be covered by their third-party payer, for which they will be held finanically responsible. Therefore, you may also insist on having some financial agreement signed by the patient, indicating that they are aware of this responsibility. For Medicare patients, although you can use Medicare's official ABN form for this purpose, we suggest that you don't. Medicare has published rules for using their form for voluntary notice, such as that the patient is not allowed to sign the form, and we think it simply complicates matters. Therefore, we suggest that you consider using your office letterhead or existing patient financial policy to notify patients of these excluded services, as a "special notice" Even better, consider using this Medicare Worksheet, offered by Patient Media instead.
There is a widely held belief that you need to have patients sign a new ABN at the start of each new year. This simply isn’t true. So... When is my Patient Required to Sign a New ABN?