What is the Advance Beneficiary Notice (ABN) in Medical Billing

Definition of Advance Beneficiary Notice (ABN)

According to the Centers for Medicare and Medicaid Services (CMS), “an ABN notice is a notice given to beneficiaries in Original Medicare indicating that coverage by Medicare is not likely to be provided for a given case.” Thus, while rendering the service or providing the item, a physician or supplier must use the ABN notice with Medicare beneficiaries.

In this discussion I will point out the diverse uses of ABNs in the healthcare revenue cycle:

• Protection for providers against financial liability
• Informed decision-making tool for patients
• Documentation of patient consent for non-covered services
• Compliance mechanism for Medicare requirements

An ABN is required for certain services- such as when an ANSI requirement is carried out for an echocardiogram, a pelvic exam for a primary care provider, or a visual field exam for an ophthalmologist medically necessary.

There are two case scenarios for the payment of these uncovered services:

• Most probably, if the physician or supplier does not furnish the ABN notice to the beneficiary with the services, then this would not end up requiring the beneficiary to pay.
• Most probably, the beneficiary will be responsible for the total payment to the physician or supplier provided that he or she signs the ABN given before service, and if, despite that, Medicare fails to pick up the tab, does it mean the benefits become payable to the provider or the doctor?

Please note that this type of notice will be used only if the beneficiary is in the Original Medicare Plan and not if the beneficiary is under the Medicare Managed Care Plan or the Private Fee-for-Service Plan.

The guidelines for ABN are given in CMS’ ABN manual—https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf.

Types of Medicare Services Requiring ABNs

• Laboratory tests that exceed frequency limitations
• Screening services outside recommended intervals
• Durable medical equipment maintenance
• Home health services lacking skilled care requirements
• Physical therapy beyond Medicare’s therapy cap
• Experimental or investigational procedures

Role of ABN in Medical Billing

The first role of ABN is to get reimbursement for the services provided to the beneficiary of the Original Medicare Plan. If your physician/supplier or medical office fails to get the ABN signed from the beneficiary then you’ll never get compensated for the services that you offered to the beneficiary. Therefore, as a medical institution, you must ensure that your physician/supplier or medical office is getting the ABN signed by the beneficiary.

A signed ABN will ensure that the beneficiary makes the full payment for the services he/she may have received at your medical institution.

Also, your staff should be aware of the services that are categorized as non-coverage services by CMS under the Original Medicare Plan. This will help your staff to pay attention to the services that require an ABN notice for reimbursement.
The second role of ABN is to make the beneficiary aware of the conditions that are necessary to get the medical services under the Original Medicare plan. This means that the beneficiary has the opportunity to accept or refuse services while agreeing to make the full payment if Medicare denies the payment.

Ensuring Reimbursement using ABN

It is correct that ABN notice is beneficial when it comes to reimbursement. However, an incorrectly filled ABN form or incorrectly used ABN may affect your revenue cycle. Therefore as a medical institution, you must ensure that the ABN:

• Must include the patient or beneficiary’s name, service offered, and estimated charge amount
• Should not be given to a patient requiring emergency treatment or who is under duress
• Must include correct modifiers

Critical Timing Considerations

• ABNs must be issued before providing services
• Cannot be issued during emergencies
• Should allow reasonable time for patient decision-making
• Must be completed for each instance of service

Documentation Requirements

• Copy of signed ABN in patient’s medical record
• Evidence of delivery method
• Date and time of issuance
• The staff member who provided the ABN
• Any relevant patient questions or concerns

Mandatory vs. Voluntary ABN Usage

Understanding when to use mandatory versus voluntary ABNs is crucial for healthcare providers. Mandatory ABNs are required in situations where Medicare is expected to deny payment for items or services under Section 1862(a)(1) of the Social Security Act. This typically occurs when services are:

• Not medically necessary for the patient’s condition
• Considered screening services beyond Medicare’s frequency limitations
• Experimental or investigational procedures
• Services performed for research purposes only

Voluntary ABNs, while not required, can be issued as a courtesy to patients when Medicare denial is possible for other reasons. However, providers should use voluntary ABNs judiciously to avoid causing unnecessary concern to beneficiaries.

Key Components of a Valid ABN Form

The CMS-R-131 form must include several essential elements to be considered valid:

• Notifier information (who is issuing the ABN)
• Patient identification information
• Description of items/services that may be denied
• The specific reason why Medicare may not pay
• Estimated cost for the items/services
• Options box for the beneficiary to choose from
• Additional information section
• Signature and date lines
• Optional: Witness signature line

ABN Delivery Requirements

To ensure compliance and effectiveness, ABNs must be:

• Delivered far enough in advance to allow the beneficiary to make an informed decision
• Presented in person when possible
• Written in plain language that the beneficiary can understand
• Available in alternative formats for visually impaired beneficiaries
• Translated for non-English speaking beneficiaries
• Properly stored in the patient’s medical record

Common Mistakes to Avoid with ABNs

Healthcare providers should be aware of these frequent ABN errors:

• Issuing blanket ABNs for all services
• Using outdated ABN forms
• Failing to provide cost estimates
• Not obtaining signatures before providing services
• Missing required fields on the form
• Using inappropriate language or medical jargon
• Not maintaining proper documentation of ABN issuance

Conclusion

The ABN, or Advance Beneficiary Notice, is crucial for modern-day healthcare billing and communicating with the patient. Though at first glance, an easy form in the world of tortuous medical documentation, it has a very significant meaning for both the provider and the patient. These coverages observe transparency in addition to safeguarding the financial interests, on the one hand, and following the Medicare laws, on the other side.

The successful implementation of the ABN signifies even more than accomplishing just getting rules followed by health facilities; it does rather insinuate that the services you offer up become substantially improved by effective customer-care concerns that can communicate with and educate patients. Indeed, as healthcare moves forward alongside cutting-edge technology and fresh payment models emerge, even more significant will be the importance of proper ABN management.

Remember that successful ABN implementation requires:

• Consistent staff training
• Clear internal procedures
• Regular updates on Medicare requirements
• Effective patient communication
• Proper documentation maintenance

Medical billing professionals and healthcare providers must continue to implement ABN requirements and best practices to maintain a healthy revenue cycle and ensure a positive patient experience.