AM designs ABN form to meet HCFA standards
New inservice tells staff what to do
With the Health Care Financing Administration (HCFA) continuing to tighten the rules regarding Medicare coverage, access managers are scrambling to help protect their hospitals’ bottom lines. HCFA announced last year that hospitals — if they want to bill Medicare patients for uncovered services — must have patients sign an advance beneficiary notice (ABN) explaining that a service may not be covered and why.
With no ABN template available from HCFA, Liz Kehrer, CHAM, manager of patient access at Centegra Health System in McHenry, IL, decided to design her own form, using HCFA guidelines. (See form, p. 46.) She went to the HCFA Web page (www.hcfa.gov) to see exactly what the form needed to contain. She also developed an ABN staff inservice. (See p. 47.) (She notes that "Medicaid" is included on Centegra’s form because the Illinois Medicaid program follows Medicare rules. That may not be true for other states.)
Previously, the Medicare notice of noncoverage given to patients listed the categories for potential denial, Kehrer points out. The new ABN, however, must be specific about the reason for denial. When the form states, for example, that a routine screening exam is not covered, it now must indicate at the bottom the specific test that — in that patient’s case — may not be covered. (See list, below.)
The most frustrating aspect of the process, Kehrer says, is that the rules keep changing, and most hospitals learn of the latest noncovered service only when they receive a denial of payment. "I have added more items [to the form] as a result of the denials we’ve received." Just recently, she says, her hospital was denied payment for 24-hour ambulatory blood pressure monitoring ordered for a patient with hypertension. HCFA put that procedure in the same category as a routine blood pressure check, she adds. "Despite the time involved, HCFA considered it a screening."
Like many of her access colleagues, Kehrer is "only trying to do the right thing, but trying to get the information to do the right thing is like pulling teeth." While the government is quick to threaten with fraud and abuse citations and fines, it offers little help to hospitals seeking advance notice of services that are not covered, she adds.
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