Advance Beneficiary Notice

The Advance Beneficiary Notice  (ABN) form was revised by Medicare in April of 2008.  There are no longer two forms available, one for lab and one for other services; there is a single form.  Starting March 1, 2009, all physicians must use the new form.

When completing the ABN, the practice should tell the patient specifically prior to the patient being prepped for the service why they think Medicare may not or will not cover the service.  It is particularly useful when you are providing a service that is sometimes covered, but might not be covered in the current situation due to frequency limitations, the diagnosis of the patient or the reason for the service being provided.  

In completing the form, it is important to say specifically what service you are going to provide, the estimated cost, and the specific reason that Medicare not pay.

Three common reasons, approved by Medicare are: Medicare does not pay for this test for your condition, Medicare does not pay for this test as often as this, (denied as too frequent), and Medicare does not pay for experimental or research services.

If a service is never covered, such as cosmetic surgery, it is not required that the office fill out an ABN.  Medicare encourages practices to do so, however, in order to have a discussion with the patient about the cost and necessity of the service.  

It is critical, however, to fill out an ABN for services that are sometimes covered and sometimes not.  For example, a service like the pelvic and breast exam, which will only be covered every two years for low risk patients and every year for high-risk patients.  In that case, if you were providing the service at a higher frequency than allowed, completing an ABN is critical.  Without the ABN signed prior to prepping the patient for the service, the practice may not hold a patient financially responsible for the service.  

There is a set of modifiers that should be used when submitting an ABN.  These are HCPCS modifiers.  These are: “GA Waiver of liability statement on file,” “GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit, or for non-Medicare insurers, is not a contract benefit,” and “GZ  Item or service expected to be denied as not reasonable or necessary.”  Use GA when you have a completed, correctly executed ABN on file.  Use GY when you are submitting a claim for a service you know is not covered and expect to be denied.  Use GZ if you should have obtained an ABN but did not.  You may not hold the patient financially responsible in this case.  

A family member may sign an ABN if the patient is unable to do so themselves. When a patient refuses to sign, but insists on receiving the service, a staff member should sign for the patient, and a second staff member should witness the signature.

It is impermissible to leave the ABN blank and ask the patient to sign a blank ABN.

It is allowable to use your own logo on the top of the ABN. The physician practice must place their name, address and phone number on the top of the notice.

The original ABN is kept in the patient's chart, and a copy is given to the patient.

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