November 12, 2013
Advanced Beneficiary Notice of Non-Coverage
On September 4, 2012 (yes, 2012) implementation of changes in manual instructions for changes in the Advanced Beneficiary Notice of Noncoverage (ABN) were presented. Some Medicare carriers like WPS were very forgiving and did not enforce the new ABN changes. However, many of the contracted Medicare carriers like National Government Services in Illinois that replaced Wisconsin Physician Services are requiring specific ABN update usage.
The applicability to Limitation on Liability (LOL) apply only when a provider believes that a Medicare covered service may be denied in a particular instance because to is not reasonable and necessary or because the item or service constitutes custodial care, which requires a provider to notify a beneficiary (patient) in advance when he/she believes that items or services billed to Medicare will likely be denied, either as not reasonable and necessary, or as constituting custodial care.
If such notice (ABN) is not given, providers may NOT shift financial liability to patients for these items or services if Medicare denies the claim. Patients are afforded “Limitation on Liability” protection when items or services are denied.
Compliance with Limitation or Liability Provisions: The Healthcare Provider who fails to comply with the ABN instructions risks financial liability and/or sanctions.
The Medicare Contractor will hold any provider who either failed to give notice when required or gave defective notice financially liable. A provider (notifier) who can demonstrate that she/he did not know, and could not reasonably have been expected to know, that Medicare would not make payment will not be held financially liable for failing to give notice.
However, a notifier who gave defective notice may not claim that she/he did not know, or could not reasonably have been expected to know, that Medicare would not make payment as the issuance of the notice is clear evidence of knowledge.
The revised ABN gives way to the Medicare Carriers to simply state; “When the provider bills Medicare and has had the patient sign an ABN on a covered service (98940, 98941, 98942), when the “GA” Modifier is used, the claim will automatically be denied as “Maintenance care”. The combination of “AT” and “GA” modifiers are NOT acceptable and can not be placed in the same billing line on the claim.
With this in mind....the “ABN” does not financially protect the doctor when billing a covered service (98940, 98941, 98942) when the patient signs an ABN and the services are denied by Medicare, since using the “GA” modifier tells the Medicare carrier to “deny the claim”. The providers financial protection is correctly documenting the Chiropractic Necessity of Care and not have the patient sign an ABN. When using the “AT” modifier, the doctor expects the Medicare carrier to pay and will not be held financially liable.
CMS Manual System Pub 100-04 Medicare Claims Processing:
"Chapter 30 Financial Liability Protections, Section 50 - Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)"
***Special Invitation: Please Join us on November 21st.
Hampton Inn Dayton-Dayton Mall, 8960 Mall Ring Rd., Dayton, OH 8:00 am to 12:00 noon. A great chiropractic Medicare Seminar covering all the important changes in Medicare and becoming compliant.
Call to register at (618) 395-3800.