VIEWS: 2 PAGES: 20 POSTED ON: 5/18/2012
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For problems downloading this presentation, please call the University Compliance Coordinator at 504-988-7721 Medicare ABNs (Advance Beneficiary Notice) The Advance Beneficiary Notice is… a written notice which a physician (or supplier) gives to a Medicare beneficiary is intended to inform a beneficiary before he or she receives specific services (or items) – that otherwise might be covered by Medicare – that Medicare probably will not pay for them on that occasion designed to allow the beneficiary to make an informed decision whether to receive the services or items for which he or she may have to pay out-of-pocket, or through other insurance Summary of Exclusions from Medicare Benefits: Personal comfort items Most outpatient Routine physicals and prescription drugs most screening tests (unless patient has Most vaccinations Medicare D) Dental care and Routine eye care, eyeglasses and dentures (most cases) examinations Orthopedic shoes and Hearing aids and foot supports hearing examinations Routine foot care Cosmetic surgery Health care received outside the USA More Exclusions… Services by immediate Home health services relatives furnished under a plan Services required as a of care, if the agency result of war does not submit the Services under a claim physician’s private Physicians’ services contract performed by a Services paid for by a physician assistant, non-Medicare midwife, psychologist, or government entity nurse anesthetist, furnished to an inpatient, Services for which the unless furnished under patient has no legal arrangements by the obligation to pay hospital And… Items and services Services of an assistant furnished to a resident of at surgery without prior a skilled nursing facility approval from the peer (SNF) or part of a facility review organization that includes a SNF, Outpatient occupational unless they are and physical therapy furnished under services incidental to a arrangements by the physician’s services SNF How do I decide if an ABN is needed? The following information is from “What Doctors Need to Know about the ADVANCE BENEFICIARY NOTICE (ABN)” published by the Medicare Learning Network http://cms.hhs.gov/medlearn/refabn.asp Will Medicare deny payment for this service? Do not give any ABN. Do submit a claim to No, I do not Medicare. expect If Medicare pays, you may collect charges from Medicare to Medicare, and any coinsurance & deductible deny from the patient. payment If Medicare denies payment for medical necessity, you may: Provide additional documentation of medical necessity Appeal on the basis that the service should be covered I don’t know. Appeal on the basis that you could not I never know reasonably have been expected to know what Medicare would not pay Medicare will If Medicare denies payment based on a statutory deny exclusion or failure to meet technical coverage requirements under the program benefits section of the law, YOU MAY COLLECT FULL CHARGES FROM THE PATIENT. Yes, I have a genuine reason to expect Medicare to deny payment. Ask, “On what basis do I expect Medicare to deny?” MEDICAL NECESSITY EXCLUSIONS & Denial as “not reasonable and TECHNICAL DENIALS necessary” All other exclusions from Do give an ABN. If the patient medicare benefits, and failure receives the services or to meet technical coverage items, you must always requirements submit a claim to Medicare Do not give an ABN. You do (called a “demand bill”) not need to submit a claim If you do not submit a claim unless the patient demands it you violate the mandatory If you do not submit a claim, claims submission provision, you may collect full charges which can result in sanctions from the patient. And…. When (or If) you submitted a claim, If Medicare Pays: Collect payment from Medicare, and any coinsurance and deductible from the patient. On an unassigned claim, you may also collect up to a 15% balance billing amount from the patient. If Medicare denies payment You may collect full charges from the patient. EMTALA (Emergency Medical Treatment and Active Labor Act) Designed to combat discriminatory practices of some hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of high costs associated with diagnosing and treating them. EMTALA (Emergency Medical Treatment and Active Labor Act) Requires that Hospitals must provide appropriate medical screening exams (MSE) to anyone coming to the E.D. seeking medical care When the hospital determines that the patient has an emergency medical condition, the hospital must treat and stabilize the medical condition, or must transfer the patient A hospital must not transfer a patient with an emergency medical condition who has not been stabilized unless conditions are met that include effecting an appropriate transfer EMTALA (Emergency Medical Treatment and Active Labor Act) If you see a patient in a setting and in circumstances to which EMTALA provisions apply, ASK, Has a Medical Screening Examination (MSE) by a qualified individual been completed? No, the MSE is not complete. 1. Do not give an ABN 1. Do not give an ABN. 2. If you do not complete 2. First, complete an an MSE, no ABN may MSE. be given 3. Stabilize the patient. 4. Then give an ABN, but only if appropriate. Yes, the MSE is complete. Is the patient stabilized? No. Yes. 1. Stabilize the patient. Give an ABN, but only if appropriate. 2. Give an ABN, but only if appropriate. Do not routinely give ABNs to all emergency department patients who are Medicare beneficiaries. Even after a patient has received an MSE and is stabilized, do not give the patient an ABN unless you have a genuine reason to expect Medicare to deny payment for the services. Giving routine ABN notices is a prohibited practice. To earn credit for this material, Download the quiz. Print the quiz and answer the questions. Fax the completed test to the University Privacy and Contracting Office at 504- 988-7777. If you have any questions, contact TUMG Business Services.
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