Medicare-ABNs by fanzhongqing


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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
    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
   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

    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
How do I decide if an ABN is

 The following information is from “What
  Doctors Need to Know about the
  NOTICE (ABN)” published by

 the Medicare Learning Network
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
                           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.
When (or If) you submitted a
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
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
No, the MSE is not complete.

   1. Do not give an ABN          1. Do not give an
   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
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