Revised ABN Requirements Still Fuzzy

March 18th, 2019 - Wyn Staheli, Director of Research

Categories: Medicare Documentation Guidelines

Although it has been quite some time since ChiroCode published an article about the revised instructions for non-participating providers who use the ABN, there are still some outstanding questions about this change. So far, Medicare has not provided additional guidance about this question despite requests by us for clarification.

Medicare now requires non-participating providers to include the following highlighted statement in the (H) Additional Information section (see this article for more information about this requirement):

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

It should be noted that Medicare's stated reason for this change was to clarify the instructions for Option 3. They stated the following regarding the problem with conflicting information on an unassigned claim (emphasis added [see References]):

The last sentence of Option 1 states, “If Medicare does pay, you will refund any payments I made to you, less co-pay or deductibles.” This statement could be true for assigned claims. However, if the claim is submitted as unassigned and the claim is determined to be payable, Medicare makes payment directly to the beneficiary for the Medicare allowed amount as payment in full. Contrary to the highlighted statement above, a refund from the supplier to the beneficiary would not be required for an unassigned claim. The Centers for Medicare & Medicaid Services (CMS) has not received any comments or questions on the ABN as it applies to unassigned claims until recently when an industry representative asked for clarification. Although the current form instructions allow for insertion of any additional information, we would like to add instructions specific to non-participating suppliers and providers who are enrolled with Medicare.

There still is an outstanding question, in the minds of some, regarding the official instructions for the ABN form for non-par providers. The title to the instructions mentions both suppliers and providers (bold emphasis added):

Special guidance ONLY for non-participating suppliers and providers (those who don’t accept Medicare assignment):

That part is clear, but in the wording that these non-par providers are supposed to include in box H, it does not mention professional services — only supplier and item. This required wording makes it sound like the instructions are only for suppliers. This is what it says (bold emphasis added):

When this sentence is stricken, the supplier shall include the following CMS-approved unassigned claim statement in the (H) Additional Information section.

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

So that makes it sound like these instructions only apply to suppliers of supplies -- NOT services supplied by providers. This could be confusing to patients because when they read this it sounds like they are getting some sort of supply. According to one consultant, sometimes providers have been referred to as suppliers by Medicare. Therefore, this might require explaining to the patient that the item(s) listed are referring to your non-covered service(s).

The official instructions state that "An ABN with the Option 1 sentence stricken must contain the CMS-approved unassigned claim statement as written above to be considered valid notice." Therefore, do NOT change the wording to say supplier/provider or provider in place of supplier. You must use the official wording for the ABN to be valid.

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