The Centers for Medicare and Medicaid Services (CMS) have revised the Advanced Beneficiary Notice of Noncoverage (ABN) form and have announced that it will delay the regulation requiring physicians to use the new version of the form (Form CMS-R-131).
It was previously reported that CMS would require the use of the new form starting Aug. 31, but due to the COVID-19 public health emergency, the agency pushed that date to Jan. 1, 2021. An ABN form is used to inform a patient in advance of receiving a service wherein Medicare may deny payment for that specific procedure or treatment. This form shifts financial liability from the physician to the patient who will be personally responsible for full payment if Medicare does not pay for the services. ABNs, therefore, can have significant financial implications for your practice, and staying on top of these changes will help maximize your profitability while focusing on patient care.
With 100 years of combined experience, Coronis Health understands the critical need for remaining up to date with the most current regulations in order to meet the ever-changing demands of the healthcare industry. We also know that your most important financial asset is your billed services and accounts receivable. We work to safeguard this asset and help you avoid medical billing and coding errors by employing a professional team possessing a perfectionist approach to accuracy, execution, organization, and timeliness.
The New ABN Form
The revised ABN replaces the ABN form that was last released in June 2017. You can use the new ABN version immediately if desired, but all uses of the older version must cease on January 1, 2021.
There are non-substantive changes to the ABN form itself, but the guidelines for dual eligible beneficiaries (patients who are dually enrolled in both Medicare and Medicaid) have been added to the form’s instructions. These individuals may be classified as a Qualified Medicare Beneficiary (QMB). A provider—whether a Primary & Specialty Physician, Hospital and Surgery Center, or Behavioral Health practice—who is treating a QMB patient may not collect deductibles or copayments for covered services. For a claim to be submitted for Medicare adjudication, dually eligible beneficiaries must be instructed to check Option Box 1 on the ABN form. The official instructions on the form state:
“Special guidance for people who are dually enrolled in both Medicare and Medicaid, also known as dually eligible individuals (has a Qualified Medicare Beneficiary [QMB]Program and/or Medicaid coverage) ONLY:
Dually Eligible beneficiaries must be instructed to check Option Box 1 on the ABN in order for a claim to be submitted for Medicare adjudication.”
Medicare asks you to strike through some of the phrases in Option Box 1 if the beneficiary is dually eligible. In the Instructions, they note:
“Strikethrough Option Box 1 as provided below: OPTION 1. I want the (D) listed above.
You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.”
Furthermore, they also state:
“These edits are required because the provider cannot bill the dual-eligible beneficiary when the ABN is furnished. Providers must refrain from billing the beneficiary pending adjudication by both Medicare and Medicaid in light of federal law affecting coverage and billing of dual-eligible beneficiaries.”
Medicare will review the other considerations pertaining to dual-eligible beneficiaries and how those claims are processed. Also included in the instructions are details regarding when it is acceptable to charge and collect from the beneficiary in advance and when it is not.
Should Medicare deny a claim where an ABN was needed to transfer financial liability to the beneficiary, the claim may be handed over to Medicaid for adjudication based on State Medicaid coverage and payment policy. Medicaid will then issue a Remittance Advice based on this determination.
To access the newest version of the ABN Form and instructions for use, visit cms.gov
Why Compliance Is Necessary
While ABNs can have a significant impact on your practice’s finances, they also serve a critical fraud and abuse compliance function. Under Medicare law, billing for unnecessary services could result in sanctions in the form of administrative, civil, and criminal penalties ranging from monetary fines and damages to prison time and exclusion from the Medicare program. ABNs can serve as a tool for rebutting an argument that claims were submitted with fraudulent intent. Particularly, these forms serve as records of the patients’ acknowledgment that the services may not be covered or may be considered medically unnecessary. The form also validates their decision to still undergo the procedure or treatment.
Adapting to the use of the new ABN form can be taken as a beneficial opportunity to assess your organization for improvements that can augment your revenue. There is no better time than now to familiarize yourself with these new rules and incorporate them into your practice. At Coronis Health, we understand that it is of critical importance that practice managers remain constantly vigilant and compliant amid the changing chorus of governmental or carrier billing and documentation regulations and compliance requirements. Allow us to help you focus on patient care as we guide you through the dynamic structure of the healthcare landscape. We adapt to new policies and regulations with accuracy and we make sure clients are 100% compliant and able to receive patients and bill either out-of or in-network. Coronis Health goes after the last dollar using our seasoned team of tireless and tough negotiators. Our clients receive timely, relevant, and accurate information in a way they can understand. We don’t just help them get money, but we help them financially grow.
Get Your Free Financial Checkup with Coronis Health
With rising operational costs and minimal reimbursement, every possible dollar collected for services is critical to your practice’s financial health. It is therefore necessary to be aware of payment rules that can help increase your revenue. Contact Coronis Health today and learn how we can help you achieve financial success and to schedule your free assessment, in which Coronis Health finds missing revenue in 95% of the assessments we perform.