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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

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