Funding Focus

The Accolades of the ABN

• By Kelly Riley
• May 01, 2009

When researching the word "accolades" in Merriam Webster's dictionary, I found four explanations. Two of those definitions explain the word to mean "a mark of acknowledgment" or "an expression of praise." Increased use of the Advance Beneficiary Notice of Noncoverage (ABN) in your day-to-day business model certainly fits both descriptions.

When used correctly, the ABN can protect and enhance your revenue stream. As of March 1, the ABN-G is no longer valid, however. In its place is the revised ABN (Form CMS-R-131). The form is available in an English and Spanish version, with detailed instructions for implementation at www.cms.hhs.gov/BNI/. The revised ABN combines the general ABN-G and the ABN-L (the ABN used by providers of laboratory services) into a single notice with an identical form number. Since the ABN is a formal information collection document approved by the Office of Management and Budget (OMB), it is subject to public comment and re-approval every three years. These latest changes incorporate suggestions for change made by suppliers/providers over the past three years of use.

According to CIGNA Government Services, some key features of the new form are that it:

• Has a new official title, the Advance Beneficiary Notice of Noncoverage (ABN), in order to more clearly convey the purpose of the notice;
• Replaces the ABN-G and the ABN–L;
• May also be used for voluntary notifications, in place of the Notice of Exclusion from Medicare Benefits (NEMB);
• Has a mandatory field for cost estimates of the items/services at issue; and
• Includes a beneficiary option, under which an individual may choose to receive an item/service and pay for it out-of-pocket, rather than have a claim submitted to Medicare.

Note that the form is intended for use by Fee-for-Service beneficiaries and is not to be used for Part D or Medicare Advantage Services.

One major reason to stock up on these forms as respiratory suppliers is the new PAP policy. March 1 marks 120 days from the Nov. 1 implementation of the new policy. The policy change now requires a face-to-face reevaluation by the treating physician sometime between day 31 and day 90 of the implementation of therapy and must include a statement that the beneficiary has improved from said therapy.

The PAP policy has caused widespread concern. Suppliers have learned that without any "skin in the game," beneficiaries are all too frequently not keeping follow-up appointments with physicians, which puts the supplier in a predicament. Suppliers are forced to either let the patient keep the equipment without getting paid or make the patient return the equipment.

The Centers for Medicare & Medicaid Services (CMS) has clarified that the ABN can be completed in advance for cases in which the supplier feels there is cause to believe the patient may not meet the medical necessity guidelines set forth by CMS at the month of billing. Providers can use the ABN to advise the patient in writing and in advance that without the documented physician follow-up, CPAP becomes a non-qualifying service. At that time, the patient can and will be billed for it. The beneficiary now has some ownership in the process, and the supplier can show a process of due diligence to concerned referral sources. Be sure to indicate which months of rental you are applying the ABN to.

This use is not considered a blanket ABN, which is a generic document obtained without a sufficient or good faith explanation of why a denial might be expected. Blanket ABNs are not allowed or even acknowledged by CMS as valid documents. Note that ABNs are only effective for one year. The supplier must obtain a new one at the end of 12 months.

Another scenario in which the respiratory supplier can take advantage of the ABN is when promoting upgraded equipment options. Upgrades are defined as items that are distinctively different from a standard item and may or may not have the same HCPCS code. For example, this may include upgrading from a standard medicine compressor (nebulizer) to one that has portable capabilities (E0570 to E0571), or from a standard CPAP unit to one with auto-titrating capabilities (E0601 to E0601).

Today's consumers are definitely savvier. Now, providers can take advantage of the mindset "this is what I want" vs. the Medicare position of "this is what they need," and start embracing the accolades of the ABN.

References: CIGNA Government Services and Andrea Stark, Medicare consultant, MiraVista LLC

This article originally appeared in the Respiratory Management May 2009 issue of HME Business.