medicare abns (advance beneficiary notices)
Post on 12-Nov-2014
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Tulane University Medical Group
Compliance Education and Training
One Compliance Credit is earned for viewing the presentation and completing thequiz (download the quiz before viewing the
presentation).
For problems downloading this presentation, please call the University Compliance Coordinator at 504-988-7721
Medicare ABNs
(Advance Beneficiary Notice)
The Advance Beneficiary Notice is…
a written notice which a physician (or supplier) gives to a Medicare beneficiary
is intended to inform a beneficiary before he or she receives specific services (or items) – that otherwise might be covered by Medicare – that Medicare probably will not pay for them on that occasion
designed to allow the beneficiary to make an informed decision whether to receive the services or items for which he or she may have to pay out-of-pocket, or through other insurance
Summary of Exclusions from Medicare Benefits:
Personal comfort items Routine physicals and
most screening tests Most vaccinations Routine eye care,
eyeglasses and examinations
Hearing aids and hearing examinations
Cosmetic surgery
Most outpatient prescription drugs (unless patient has Medicare D)
Dental care and dentures (most cases)
Orthopedic shoes and foot supports
Routine foot care Health care received
outside the USA
More Exclusions…
Services by immediate relatives
Services required as a result of war
Services under a physician’s private contract
Services paid for by a non-Medicare government entity
Services for which the patient has no legal obligation to pay
Home health services furnished under a plan of care, if the agency does not submit the claim
Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, furnished to an inpatient, unless furnished under arrangements by the hospital
And…
Items and services furnished to a resident of a skilled nursing facility (SNF) or part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF
Services of an assistant at surgery without prior approval from the peer review organization
Outpatient occupational and physical therapy services incidental to a physician’s services
How do I decide if an ABN is needed?
The following information is from “What Doctors Need to Know about the ADVANCE BENEFICIARY
NOTICE (ABN)” published by
the Medicare Learning Networkhttp://cms.hhs.gov/medlearn/refabn.asp
Will Medicare deny payment for this service?
No, I do not expect Medicare to deny payment
I don’t know. I never know what Medicare will deny
Do not give any ABN. Do submit a claim to Medicare.
If Medicare pays, you may collect charges from Medicare, and any coinsurance & deductible from the patient.
If Medicare denies payment for medical necessity, you may: Provide additional documentation of medical
necessity Appeal on the basis that the service should
be covered Appeal on the basis that you could not
reasonably have been expected to know Medicare would not pay
If Medicare denies payment based on a statutory exclusion or failure to meet technical coverage requirements under the program benefits section of the law, YOU MAY COLLECT FULL CHARGES FROM THE PATIENT.
Yes, I have a genuine reason to expect Medicare to deny payment. Ask, “On what basis do I expect Medicare to deny?”
MEDICAL NECESSITY
Denial as “not reasonable and necessary”
Do give an ABN. If the patient receives the services or items, you must always submit a claim to Medicare (called a “demand bill”)
If you do not submit a claim you violate the mandatory claims submission provision, which can result in sanctions
EXCLUSIONS & TECHNICAL DENIALS
All other exclusions from medicare benefits, and failure to meet technical coverage requirements
Do not give an ABN. You do not need to submit a claim unless the patient demands it
If you do not submit a claim, you may collect full charges from the patient.
And….
When (or If) you submitted a claim,
If Medicare Pays:
Collect payment from Medicare, and any coinsurance and deductible from the patient.
On an unassigned claim, you may also collect up to a 15% balance billing amount from the patient.
If Medicare denies payment
You may collect full charges from the patient.
EMTALA (Emergency Medical Treatment and Active Labor Act)
Designed to combat discriminatory practices of some hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of high costs associated with diagnosing and treating them.
EMTALA (Emergency Medical Treatment and Active Labor Act)
Requires that Hospitals must provide appropriate medical
screening exams (MSE) to anyone coming to the E.D. seeking medical care
When the hospital determines that the patient has an emergency medical condition, the hospital must treat and stabilize the medical condition, or must transfer the patient
A hospital must not transfer a patient with an emergency medical condition who has not been stabilized unless conditions are met that include effecting an appropriate transfer
EMTALA (Emergency Medical Treatment and Active Labor Act)
If you see a patient in a setting and in circumstances to which EMTALA provisions apply, ASK,
Has a Medical Screening Examination (MSE) by a qualified individual been completed?
No, the MSE is not complete.
1. Do not give an ABN
2. If you do not complete
an MSE, no ABN may
be given
1. Do not give an
ABN. 2. First, complete an
MSE. 3. Stabilize the patient. 4. Then give an ABN,
but only if appropriate.
Yes, the MSE is complete.
Is the patient stabilized?
No. Yes.
1. Stabilize the patient. Give an ABN, but
only if appropriate.
2. Give an ABN, but only
if appropriate.
Do not routinely give ABNs to all emergency department patients
who are Medicare beneficiaries.
Even after a patient has received an MSE and is stabilized, do not give the patient an ABN unless you have a genuine reason to expect Medicare to deny payment for the services.
Giving routine ABN notices is a prohibited practice.
To earn credit for this material,
Download the quiz.Print the quiz and answer the questions.Fax the completed test to the University
Privacy and Contracting Office at 504-988-7777.
If you have any questions, contact TUMG Business Services.
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