ABN Discussion

Newsletter
July 23, 2012
Chiropractic Medicare

The basic purpose of Section 1879 of the Social Security Act, the limitation of liability provision (ABN) is to protect the beneficiaries (Patients) from liability in denial cases under certain conditions when items they receive are found to be excluded from coverage as NOT reasonable and necessary under section 1862 (a) (1) (A) of the Federal Security Act.

Where items or services are denied because they are determined to be not reasonable and necessary, the Medicare program makes payment when neither the beneficiary (patient) nor physician or supplier knew, and could not reasonably be expected to know, that the items or services were excluded.

When the beneficiary did not have such knowledge, but the physician or supplier knew, or could have been expected to know of the exclusion of items or services, the liability for the charges for the denied items or services rests with the physician or supplier.

If an ABN is not presented to the patient for those services or supplies that day prior to those services, the doctor will not be reimbursed by the Medicare Carrier if a participating provider and can not receive payment from the patient, or as a non-participating provider, the denial EOB will tell the patient to return to the doctor for a refund of what they paid at time of services. 

http://www.cms.gov/BNI/02_ABN.asp
http://www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

The bottom line....the ABN is your friend.  You should make an assessment each office visit.  If you determine any service, covered or not, that you bill to Medicare may be denied today, you have the privilege of asking the patient to take financial responsibility by them signing an ABN today.

My Congressman's office called this morning.... Still waiting on CMS to give to me the official usage of option #2 on the ABN... keep watching.

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It is my goal to help Chiropractors and their staff understand Chiropractic Medicare so they are successful with Medicare, keep out of trouble, provide the adjustments our Medicare patients NEED, and bill claims correctly so we, not only stay in Medicare, but so Chiropractic will be included in future governmental health plans.

I am not a paid consultant.  I have excellent products containing information that may be purchased at a reasonable price.  I also believe in follow-up, so if you purchase some of our products, I will be available by phone or email to do my best to answer any questions you may have.
Thanks,
Dr. Street

If you do not have our information, you can visit our website or give us a call.  You will be so happy you have this information.

Still waiting on CMS to give to me the official usage of option #2 on the ABN... keep watching.

Remember....we all must become Medicare Compliant by the end of this year.

ABN Option #2 ~ Newsletter 7/2/2012

NewsletterJuly 2, 2012Chiropractic MedicareABN Option #2

Since posting my prior newsletters about ABN there has been considerable interests and questions  in regard to Option #2.

Option #2 on the ABN states, "I want the (Blank) listed above, but do not bill Medicare.  You may be asked to be paid now as I am responsible for payment.  I cannot appeal if Medicare is not billed.”

Option #2 is for ONLY non-covered services.

The Chiropractic adjustment is the only covered service for Chiropractors.

 National Government Services issued a "What's New" article on 6/27/12 with their explanation of the understanding of Option #2 as follows:

1. Option #2 of the ABN is to be used when a Chiropractor is providing a service to a Medicare beneficiary that is not going to be covered by Medicare.  The confusion has come in from some that believe Option 2 can only be utilized by the Chiropractor for the patient when the service is statutorily non-covered.  However, that is not the case.

2. The description for Option #2 indicates that the provider has told the beneficiary that Medicare will not cover the service because it does not meet policy criteria; therefore, it will be a non-covered service.  By selecting Option #2 the patient is authorizing that they still want the service to be performed and that they will pay the practitioner for the service.  Option #2 also alerts the beneficiary that a claim will not be filed to Medicare and that they have no appeal options.

3. The misunderstanding is that since the Chiropractic service is a Medicare benefit, just not covered for this specific scenario, that Option #2 should not be used.  The belief is that the Chiropractic adjustment is always a covered service; however it is not always covered, it is simply recognized as a Medicare benefit.  This also leads to the misunderstanding that Chiropractic adjustments must always be billed to the Medicare carrier for consideration.  With the implementation of the new ABN form, this is no longer the case.  Providers are allowed to provide a service to a beneficiary that they know will be non-covered by Medicare according to policy and the patient has the right to still have that service, pay the provider for that service and waive the filing of a claim to Medicare.

4. The Centers of Medicare & Medicaid Services (CMS) Internet-only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.14.1 (1.07 MB) states that in this situation the provider will not be violating "Mandatory Claim Submission" guidelines:

"Note:  Providers will not violate mandatory claims submission rules under Section 1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiary's written request in choosing Option #2 on the revised ABN."

If this is true, now the patient has the authority to mark Option #2 and it supersedes "Mandatory Claims Submission" and the "Participating Provider Contract" of not collecting the 80% of the fees at time of visit.  This also denies the patient from reimbursement for the covered service of the adjustment.  It also is another way cut Chiropractic reimbursement.

I am awaiting official explanation from CMS that I shall share as quickly as I receive.

Remember, we all must become Medicare Compliant by the end of this year!

Have questions? Give Dr. Street a call today at (618) 395-3800.

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Keep in mind, Medicare is the only insurance type program that if done incorrectly is fraud, a felony, a fine and/or jail.

Resources and further reading:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractors_fact_sheet.pdf

NGS pdf document  "869c_910_Notices_of_Noncoverage.pdf"

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7821.pdf