Providers are protected from liability when services rendered to Medicare patients are denied as not reasonable and necessary if the provider gives the patients proper advance notice that Medicare is not likely to pay and the patient agrees to pay for the item or services.
A valid advanced beneficiary notice (ABN) must be in writing, dated and signed by the patient. It also must inform the patient of why a particular service may not be covered. Following are some examples of acceptable statements of reasons for which Medicare may deny payment:
- Medicare never pays for this item or service (i.e. acupuncture).
- Medicare does not pay for this item or service more often than frequency limit (i.e. mammography screening, pap smear, colorectal cancer screening).
- Medicare usually does not pay for this service for this condition.
- Medicare usually does not pay for this many services for this condition.
- Medicare does not pay for this treatment because its effectiveness has not been proven.
- Medicare usually does not pay for two surgeons for this procedure.
- Medicare usually does not pay for similar services by more than one doctor during the same time period.
- Medicare does not pay for an item or service that it considers experimental or for research purposes.
Medicare ABNs must be produced in a format designed by the federal government, and the requirements are somewhat more complicated than described above. For information about the use of ABNs in your practice, speak with your practice manager. For additional background information about ABNs and how they fit into BWH’s compliance initiatives, call Neil Walsh at 617-732-9377.