Health Care Collector - Kluwer Law International
Health Care Collector - Kluwer Law International
Health Care Collector - Kluwer Law International
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PAGE5<br />
procedure was not covered. Procedures may not be<br />
properly investigated and screened prior to service<br />
in order to make sure that an ABN is signed,” says<br />
Stephen Chrapla, Director of Third Party Solutions<br />
for Revenue Cycle Partners, LLC, in Billings,<br />
Montana.<br />
“Claims should be also be checked prior to submission<br />
and, if the service is not covered by Medicare,<br />
the claim should not be submitted. The charge would<br />
have to be written off. If the claim is submitted, it<br />
could potentially be considered an abusive billing<br />
practice and subject to fines under Medicare Fraud<br />
and Abuse regulations,” Chrapla says.<br />
Shapiro concurs. “There is no ‘back end’ procedure<br />
for ABNs. If you have provided the service without<br />
the patient being informed or signing off on the<br />
charge, you may not bill. Anything other than that is<br />
called fraud,” she says.<br />
That is why getting the ABN signed during the registration<br />
process is so important. “What often creates<br />
a problem is not that the patients don’t sign, but that<br />
they sign and are not aware of having done so. During<br />
inpatient and outpatient registration, there are<br />
so many forms for people to sign; they may not really<br />
register having signed the ABN. Because ABNs are<br />
for Medicare patients, and the majority of Medicare<br />
patients are elderly, you may have a confusion factor<br />
anyway,” Shapiro says.<br />
The Appeal<br />
“If a patient has not signed an ABN or even if<br />
they have signed it but the hospital deems that the<br />
service should be covered, then they have to appeal<br />
Medicare’s decision to pay due to medical necessity,”<br />
Shapiro says. “Of course, the ABN cannot be signed<br />
after the fact when services have been rendered, but<br />
appeals can be made. Once the service is provided,<br />
the ABN is irrelevant in the appeal process,” she<br />
says.<br />
In the appeal process, the physicians are asked to<br />
provide additional diagnoses and information to get<br />
a service approved. “ABNs state that if the patient<br />
receives non-medically necessary and/or non-covered<br />
services, they are required to pay for the service. If<br />
they receive a service that Medicare deems not necessary,<br />
the provider might be able to end run the<br />
process by changing the diagnosis to something that<br />
Medicare will cover. This does not mean having<br />
the patient sign an ABN after the fact of service—it<br />
means changing the facts of service so that it would<br />
be covered,” Shapiro says.<br />
These appeals are very difficult and time consuming,<br />
Shapiro says. “The process requires coordination<br />
among the different departments, such as IT, registration,<br />
and patient accounts, so that future issues don’t<br />
arise. Because it is so difficult, some hospitals just<br />
write off the smaller amounts rather than take the<br />
time,” she says. ■<br />
Biller’s Corner<br />
Why You Need to Understand<br />
Medicare Appeals, Part II<br />
Medicare Advantage Plans<br />
Judy I. Veazie, CPAM<br />
A<br />
Medicare Advantage plan is a health coverage<br />
choice for Medicare beneficiaries<br />
besides traditional Medicare. Medicare<br />
Advantage plans, sometimes called “Part C” or “MA<br />
plans” are offered by private companies approved by<br />
Medicare. Through a bidding process, these private<br />
payers must submit plans and assurances that they<br />
can meet the established standards and rules for<br />
processing claims under the Medicare system. Under<br />
these rules, the Centers for Medicare & Medicaid<br />
Services (CMS) intend to reassure the beneficiary<br />
and the provider that they can count on fair treatment<br />
by the MA plans.<br />
When a beneficiary joins an MA plan, the plan<br />
assures that it will provide all Part A (hospital<br />
HEALTH CARE COLLECTOR AUGUST 2010