HCFA unveils changes in advance notice form
New form more physician-friendly
The Health Care Financing Administration (HCFA) is promoting a new advance beneficiary notice (ABN) it says physicians will find easier to use. The first unofficial reaction from the American Medical Association to the changes is that "HCFA needs to be complimented for the work they did on this," said AMA Trustee J. Edward Hill, MD. The ABN form is used to notify patients that Medicare might not pay for a service recommended by their doctor. Many physicians have had problems with the current form, arguing that its language gives the impression that they recommend medically unnecessary care.
In contrast, the new, one-page ABN form removes existing language that Medicare only pays for medical items and services it feels are "reasonable and necessary." Instead, the revised ABN says: "Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it."
The proposed form also asks beneficiaries to check a box indicating whether they still want to receive the item or service in question. It also states they can appeal Medicare’s decision not to pay for it. A sticking point still remains with the new form, say some physicians. Specifically, there are conflicts with the Emergency Medical Treatment and Active Labor Act (EMTALA). Under present regulations, physicians must give Medicare beneficiaries the ABN before treatment is provided. However, EMTALA says doctors and hospital staffs can not inquire about a patient’s insurance status in an emergency situation before their condition is stabilized.
Besides coding and documentation mistakes, there are three basic reasons Medicare will deny payment:
• Medicare will not pay for non-covered services that have never been covered by Medicare under any conditions. These services include such items as routine checkups and certain immunizations or drugs. Because it is clear the beneficiary is responsible for payment, no ABN waiver is necessary.
• Medicare will not reimburse for services deemed not medically necessary by HCFA or local carriers. In this situation, the beneficiary should sign a waiver of liability in advance, expressly making himself or herself responsible for payment.
Tip: A modifier -GA added to the end of the CPT code indicates to the carrier that the patient has signed a waiver of liability.
• Unbundled services cannot be billed to a Medicare beneficiary. For instance, if a provider gives a patient an injection and performs an evaluation and management (E&M) service on the same day, the physician cannot separately bill Medicare for the E&M and the patient for the shot. HCFA considers the injection to be included in the E&M service payment. Billing the beneficiary separately for the shot would be classified as unbundling, and patients are not responsible for paying for unbundled services under Medicare.
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