Demystifying the Medicare ABN

Have you been issuing ABNs, but are unsure whether it’s appropriate? Are you uncertain if ABNs are relevant to you as a provider not enrolled in Medicare? Keep reading to learn when and why to use ABNs.

Demystifying the Medicare ABN

The Medicare program, which serves disabled and elderly patient populations, has a process by which healthcare professionals can notify patients that Medicare may not cover a procedure—an Advance Beneficiary Notice of Non-coverage (ABN).

What is the purpose of the ABN?

Many of the patient populations which Medicare serves are on a fixed income. The ABN allows patients to make an informed decision about pursuing treatment or a procedure that may not be paid for by Medicare. When the patient reads and signs the ABN, that document will serve as proof that the patient received notification about their potential responsibility for the service. 

Who can issue ABNs to patients?

An ABN should be issued by physicians and practitioners to Medicare beneficiaries who have Original Medicare. Practitioners should issue ABNs when they reasonably believe that Medicare may not cover the cost of a service or procedure for these beneficiaries. 

To complicate matters, only practitioners that are opted in with Medicare should issue ABNs. Currently, only physicians and a few other practitioners can opt-out of Medicare. The non-physician practitioners who can choose to opt-out of Medicare include: doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives, clinical psychologists, clinical social workers, registered dieticians, and nutrition professionals.

The providers authorized to opt-out must submit an affidavit to Medicare expressing the decision to opt-out of the program. Those who chose to opt-out do so for two years. Opting out of Medicare means that neither the opted-out provider nor the patient will bill Medicare for the opted-out provider’s medical services during those two years. For example, if you are a physician who has chosen to opt-out of Medicare, you should not issue ABNs to patients during the period when you have opted out of Medicare. To put it simply, if you are officially out, you should not use Medicare forms. 

If I’m not associated with Medicare, should I issue ABNs?

No. If you are a physical therapist, for example, and you have no relationship with Medicare, you should not be issuing ABNs to Medicare patients. In addition, you should not treat or charge these patients for Medicare-covered services, as dictated by the Mandatory Claims Submissions Rule. In contrast, you may provide non-Medicare-covered services to Medicare beneficiaries, such as wellness services. 

However, if you are a physical therapist enrolled in Medicare, you must bill Medicare for any and all covered services provided to Medicare patients. In this situation, if the patient wants to receive non-medically necessary services, you should issue an ABN. The ABN notifies the patient that they may be financially responsible for the service because Medicare may not cover it. 

Will providing a patient with an ABN opt me into Medicare?

This is a common misconception. The short answer is no. If you are a physical therapist or chiropractor who has no relationship with Medicare, giving a patient an ABN does not create a relationship with Medicare. Enrolling with Medicare is a separate process, and it requires much more than issuing an ABN to a patient. 

However, if you do not want to enroll with Medicare, and if you are not enrolled with Medicare when you issue the ABN, the ABN is a meaningless document. If you are enrolled with Medicare and providing a non-medically necessary service that Medicare may not cover, an ABN is required. 

What happens if I forgot to issue an ABN to the patient, and Medicare denied coverage?

Unfortunately, this question raises the importance of giving the patient an ABN before rendering any services which may not be medically necessary and may not be covered by Medicare. If you fail to get an appropriately filled out and signed ABN before rendering services to the patient, and Medicare denies the claim, you cannot get paid (and you may have to pay back any funds already paid).

Correctly completing and issuing an ABN to patients can serve dual purposes. First, it notifies the patient of their potential responsibility, allowing them to make an informed decision. Second, it permits your practice to bill the patient once Medicare denies the claim.

 ABNs are just one of the many complicated processes that are part and parcel of Medicare. If you have any concerns regarding ABNs or other Medicare regulatory requirements, please contact the experienced healthcare attorneys at Jackson LLP Healthcare Lawyers. 

This blog is made for educational purposes and is not intended to be specific legal advice to any particular person. It does not create an attorney-client relationship between our firm and the reader. It should not be used as a substitute for competent legal advice from a licensed attorney in your jurisdiction.

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