MD - Health Care Compliance Association

By Susan C. L. Theuns
Editor’s note: Susan C. L. Theuns, It is at this point where many providers have
PA-C, CPC, CHC, is Operations difficulty understanding how they personally
Administrator & Compliance Director expect that medical necessity has been met
with MedStar Physician Partners. She and yet Medicare does not agree with them.
may be reached by telephone at
That’s because the determination of “medical
443/725-8713.
necessity” is not provider driven. Medical
necessity is established by Congress, the U.S.
There are a variety of ways that a Department of Health and Human Services
compliance program can improve (DHHS) and the Centers for Medicare and
the bottom line. One way is to Medicaid Services (CMS). Keeping this point
avoid expenses, such as being proactive with in perspective will help you follow the general
schematic of the process when dealing
coding audits to save you from fines and
penalties. Identifying high-level coders can with ABNs in the office practice setting.
also save you unwanted payer audits and possible
refunding. But one way to actually Additionally, an ABN must be completed
improve revenue is through the proper use of before the service has been provided. That
Advance Beneficiary Notices (ABNs). means that the office must be organized and
know their providers’ protocols and paradigms
when seeing scheduled patients.
Proper completion and use of ABNs can
■ reduce write-offs
■ improve cash flow
The ABN form
■ recoup potential or real lost revenue ABN forms have actually been around for
more than 20 years. The federal government
What is an ABN
has since developed the official ABN form,
An ABN is actually a waiver of liability that which is available at www.cms.hhs.gov
shifts the financial responsibility directly to the /medicare/bni/. CMS makes them available
patient. Most providers are contracted with in both English and Spanish as well as a general
use form and laboratory services form.
Medicare and are required to “accept assignment.”
The ABN allows a provider to bill the For simplicity, this article will be focusing on
patient if the service provided is not covered by the general use form. The version on this
Medicare (in other words, coverage is denied). Web site, June 2002, is the only version that
In situations where Medicare does not cover a providers should be using currently. Note that
service for lack of “medical necessity” or due to there are requirements when reproducing this
frequency guidelines, the ABN form notifies form—chiefly that the content remains the
the patient in advance of receiving the service same and that the font is a minimum of 12
that non-coverage is likely. Note that ABNs are point so that it is more readily readable. The
not needed for covered services or “sick visits.” form number is CMS-R-131-G.
Performing an ABN audit
Initially, the easiest way to audit your ABN
use is to run a billing report for the use of
the –GA modifier. The –GA modifier signifies
that a signed ABN has been obtained
and tells the payor (Medicare), that you have
an ABN and will be balance-billing the
patient if Medicare denies payment for the
service. Once you have the report (I would
suggest limiting the time to a six-month period),
you can randomly select five or 10 uses
of the –GA modifier per provider. In theory,
the medical office should be able to produce
a copy of the ABN for the corresponding use
of the ABN.
If the office is able to produce the corresponding
ABN, that’s a positive step. If they cannot—that
is indicative of a key problem that
needs to be addressed immediately. Of the
ABNs that they are able to produce, look at
the fields that are required to be completed,
see if they chose option 1 or option 2, and
whether or not the form has been signed and
dated. Having the ABN is only the first step;
many problems arise from there. In order for
it to be a legal document, all the necessary
fields need to be completed, an option must
be checked off, and it must be both dated
and signed.
What if they refuse to sign
Many patients, when faced with signing a
form that will make them financially responsible,
will simply refuse. If they are refusing
the service, then document their refusal.
However, most of the time, they want the
service but just don’t want to sign the form.
Patients think if they don’t sign the form but
get the service, it will be free. If they have
said that they want the service but refuse to
sign, simply fill out the ABN as you normally
would, check off option 1 (“yes, I want the
service”) and have a staff member who wit-
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Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
9
January 2006