Wound care professionals often make the mistake of not offering a service, procedure, or product to a patient when it is not covered by his/her insurance. Some wound care patients have been waiting a long time for their wounds to heal, which means they have also been paying coinsurance for a long time. If a service, procedure, or product is available that may possibly reverse this situation, wound care professionals should educate patients about their options and let them decide what they can afford. Clinicians should not assume a patient will not want the service, procedure, or product.
If the patients have traditional Medicare Part A and Part B insurance, the Centers for Medicare & Medicaid Services (CMS) uses the Fee-for-Service Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, to inform Original Medicare beneficiaries when Medicare may deny payment for an item or service. For the ABN to be valid, providers must use the ABN form currently approved by the Office of Management and Budget (OMB). The ABN form was recently reviewed by the OMB, who made 3 changes to the form:
- Added language to tell the patient that CMS does not discriminate: CMS does not discriminate in its programs and activities.
- Added language to tell patients how to request the ABN in a different format: To request this publication in an alternative format, please call 1-800-MEDICARE or e-mail: [email protected].
- Changed the expiration date on the bottom left side of the form to read (Exp. 03/2020).
The “correct” ABN form is available at: www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html.
Because wound care professionals continue to ask many questions about how to correctly use the Medicare ABN, let’s review the most common questions that this author receives.
Q: What providers should issue the ABN?
A: The ABN must be used by “notifiers” that include the following:
- all providers and suppliers of Part B services and
- the following providers of Part A items and services:
- ○ hospice providers
- ○ home health agencies, and
- ○ religious nonmedical healthcare institutions.
Q: When must a wound care professional offer an ABN to a Medicare beneficiary?
A: Give a Medicare beneficiary an ABN for a service, procedure, or product that Medicare normally covers, but the notifier believe Medicare will deny payment in this beneficiary’s particular situation. For example, a Medicare Part B–covered beneficiary has had a chronic pressure ulcer for several years. The wound care notifier has unsuccessfully tried many procedures and products, for which the patient has already paid a significant amount of coinsurance. The instructions for use of a particular cellular and/or tissue-based product (CTP) for skin wounds states that the CTP may be used on pressure ulcers, but the Medicare Administrative Contractor in that Jurisdiction has a local coverage determination that covers that CTP only for diabetic and venous ulcers. Nevertheless, the notifier believes the CTP may work for this patient’s pressure ulcer. Therefore, the notifier carefully describes the CTP to the patient and explains that it will probably not be covered by Medicare, but he will be glad to apply it to the patient’s pressure ulcer. The notifier then carefully reviews the ABN with the patient.
Q: How can notifiers determine whether they are using the “correct” ABN form?
A: For the ABN to be valid, notifiers must use the ABN form currently approved by the OMB. The ABN form was recently reviewed by the OMB and has the following words in the lower left corner: (Exp. 03/2020). All notifiers should verify that they have converted to the most recent ABN form. The one dated 03/11 in the lower left corner is not valid after June 20, 2017.
Q: Can notifiers fill in parts of the ABN in advance?
A: Yes, notifiers can fill in the name and contact information for the practice in section A, the item or service covered by the ABN in section D, and the estimated cost in section F.
Note: If the contact information for the notifier’s billing office is different from the practice information in section A, provide the billing office’s contact information in section H.
Q: If the notifier personally explains to the patient the reason he/she believes Medicare will not cover the service, procedure, product, is it necessary to write that reason on the ABN?
A: Yes. In section E of the ABN, the notifier should write, in a way the patient can understand, the patient-specific reason Medicare may not pay.
Q: Exactly what is the beneficiary’s liability if he/she signs and dates the ABN?
A: A beneficiary who has been given a properly written and delivered ABN and agrees to pay may be held liable. The charge may be the notifier’s usual and customary fee for that item or service and is not limited to the Medicare fee schedule. If the beneficiary does not receive a proper ABN when required, he/she is relieved of liability.
Note: Notifiers may not issue ABNs to shift financial liability to a beneficiary when full payment is made through bundled payments. In general, ABNs cannot be used when the beneficiary would otherwise not be financially liable for payment for the service because Medicare made full payment.
Q: When does the notifier have financial liability?
A: The notifier will likely have financial liability for items or services if he/she knew or should have known that Medicare would not pay and failed to issue an ABN when required or issued a defective ABN. In these cases, the notifier is precluded from collecting funds from the beneficiary and is required to make prompt refunds if funds were previously collected. Failure to issue a timely refund to the beneficiary may result in sanctions.
Q: How long is the ABN effective?
A: The ABN can remain in effect for up to 1 year. Notifiers may give a beneficiary a single ABN describing an extended or repetitive course of noncovered treatment, provided the ABN lists all items and services that the notifier believes Medicare will not cover. If applicable, the ABN must also specify the duration of the treatment period. If there is any change in care from what is described on the ABN within the 1-year period, a new ABN must be given. If additional noncovered items or services are needed during the course of treatment, the notifier must give the beneficiary another ABN. There is a 1-year limit for using a single ABN for an extended course of treatment. A new ABN is required when the specified treatment extends beyond 1 year.
Q: What should a notifier do if a beneficiary is receiving repetitive noncovered care, but the notifier failed to issue an ABN before the first or the first few episodes of care?
A: The ABN may be issued at any time during the course of treatment. However, if the ABN is issued after the repetitive treatment was initiated, the ABN cannot be retroactively dated or used to shift liability to the beneficiary for the care that was provided before the ABN was issued. In cases such as this, care that was provided before the ABN was delivered to the beneficiary is the financial responsibility of the notifier.
Q: Should the notifier provide the Medicare beneficiary with a copy of the signed and dated ABN?
A: Yes, a minimum of 2 copies (including the original) must be made so that both the beneficiary and the notifier have one; the notifier should retain the original whenever possible.
Q: What should notifiers do if the beneficiary refuses to complete or sign the ABN?
A: If the beneficiary, or the beneficiary’s representative, refuses to choose an option and/or refuses to sign the ABN when required, the notifier should annotate the original copy of the ABN and indicate the refusal to sign or choose an option in the additional information section H. Notifiers may list any witnesses to the refusal on the ABN, although Medicare does not require a list of witnesses. In addition, if a beneficiary refuses to sign a properly issued ABN, notifiers should consider not furnishing the item or service unless the consequences (health and safety of the beneficiary, or civil liability in case of harm) prevent this option.
In any case, notifiers must provide a copy of the annotated ABN to the beneficiary and must keep the original version of the annotated ABN in the patient’s file.
Q: What should notifiers do if the beneficiary changes his/her mind after completing and signing the ABN?
A: The notifier should present the previously completed ABN to the beneficiary and request that he/she annotate the original ABN. The annotation must include a clear indication of his/her new option selection, along with the beneficiary’s signature and date of annotation. In situations where the notifier is unable to present the ABN to the beneficiary in person, the notifier may annotate the form to reflect the beneficiary’s new choice and immediately forward a copy of the annotated notice to the beneficiary for him/her to sign, date, and return.
In both situations, a copy of the annotated ABN must be provided to the beneficiary as soon as possible. If a related claim has been filed, it should be revised or cancelled (if necessary) to reflect the beneficiary’s new choice.
Q: Is an ABN required for services, procedures, or products that are never covered by Medicare?
A: No. The ABNs are not required for such services, for example, routine foot care, but the ABN can be issued voluntarily as a courtesy to forewarn the beneficiary of their financial obligation. In that case, the beneficiary should not be asked to choose an option box or to sign the ABN.
Q: For how long should notifiers save ABNs?
A: For a full discussion of applicable retention periods for the ABN, please read Chapter 1 §110 of the Medicare Claims Processing Manual. In general, the ABN retention period is 5 years from discharge/completion of delivery of care when there are no other applicable requirements under state law. Retention is required in all cases, including those cases in which the beneficiary declined the care, refused to choose an option, or refused to sign the ABN. Electronic retention of the signed paper document is acceptable. Notifiers may scan the ABN for electronic medical record retention and, if desired, give the paper copy to the beneficiary.
Q: Should notifiers use the ABN form for patients with Medicare Advantage?
A: No. The ABN requirements do not apply to Medicare Advantage because wound care professionals are required to contact the Medicare Advantage payer for clearance and must receive approval before supplying the service, procedure, or product. Medicare Advantage enrollees have the right under the statue and regulations to an advance determination of whether services are covered prior to receiving the services. If the Medicare Advantage plan denies the service and the patient wants to proceed with the service, the notifier should hold the patient responsible for payment via a form created by the notifier; do not use the Medicare ABN.
Q: Is the ABN used for prescription drugs under the Medicare Prescription Drug Program (Part D)?
A: No. The ABN is not used for the Medicare Part D program.
Q: How do notifiers correctly complete all the fields of the ABN?
A: Let’s review how to complete each of the lettered sections of the most current ABN displayed in the Figure.
A. Notifier: Place the provider/supplier name, address, and telephone number (include TTY, if applicable) at the top of the ABN. Include the facility’s logo at the top of the notice. When the notifier is not the billing entity for the item or service (eg, a physician’s office that collects laboratory specimens and sends them to a laboratory for processing), the notifier must also list contact information for the billing entity in either the Notifier section A or in the Additional Information section H. When more than one entity is listed on the notice, the Additional Information section H must specify whom to contact for billing questions.
B. Patient Name: Enter the first and last name of the beneficiary receiving the ABN. Use the middle initial if it appears on the beneficiary’s Medicare card.
C. Identification Number: This field is optional and can include an identifier, such as a medical record number or date of birth. Do not use Medicare numbers, Health Insurance Claim Numbers, or Social Security Numbers.
First D Field in ABN: Notifiers should list the general description of what they believe Medicare may not cover on the blank line. Examples of descriptors include Item(s)/Service(s), Laboratory test, Test, Procedure, Care, and Equipment.
Notifiers may prefill all of the section D fields on their ABN template with “Items(s)/Service(s)” if desired.
Second D field in ABN: Insert the wording used in the first D field.
First column in Table D: For the column header, insert the wording used in the first D field. In the table, under the column D header, list the specific items and services you believe are not covered using language the beneficiary understands. General descriptions of specifically grouped supplies are permitted. For example, “wound care supplies” is a sufficient description of a group of items used to provide this care. An itemized list of each supply is generally not required.
- In the case of partial denials, list the excess component(s) of the item or service for which denial is expected.
- For repetitive or continuous noncovered care, specify the frequency and/or duration of the item or service.
- For reduction in service, provide additional information so the beneficiary understands the nature of the reduction. For example, stating “wound care supplies decreased from weekly to monthly” is appropriate to describe a decrease in frequency for this category of supplies; stating “wound care supplies decreased” is insufficient.
Note: For the ABN to be considered valid, all blank fields in section D of the ABN must be completed.
E. Reason Medicare May Not Pay: Explain in beneficiary-friendly language why Medicare may not cover each item or service listed in the column under D. Commonly used reasons for noncoverage are as follows:
- Medicare does not pay for XXX for your condition
- Medicare does not pay for XXX at this frequency (denied as too frequent); and
- Medicare does not pay for experimental or research use XXX.
Note: To qualify as a valid ABN, at least 1 reason must apply to each item or service listed in column D. Notifiers may apply the same reason to multiple items in column D.
F. Estimated Cost: Notifiers must complete this column to ensure the beneficiary receives all available information to make an informed decision about whether to obtain potentially noncovered services and to accept financial responsibility if Medicare does not pay.
Notifiers must make a good-faith effort to insert a reasonable estimate for all the items or services listed under column D. In general, Medicare expects the estimate to fall within $100 or 25% of the actual costs, whichever is greater. The following are some examples of acceptable estimates:
For a service that costs $250,
- any dollar estimate equal to or greater than $150,
- between $150 and $300, and
- no more than $500.
For a service that costs $500,
- any dollar estimate equal to or greater than $375,
- between $400 and $600, and
- no more than $700.
Notifiers can bundle routinely grouped items or services into a single cost estimate.
Field D. Under “What You Need to Do Now”: Insert the wording used in the first section D field.
Field D. Under G. Options: Insert the wording used in the first section D field.
G. Options: Complete the 3 section D fields under the Options section G with the same wording used in the first section D field. The beneficiary, or his/her representative, must choose 1 of the 3 options listed. Medicare does not permit notifiers to make this selection. (However, home health agencies caring for dual eligibles [beneficiaries eligible for both Medicare and Medicaid] may direct beneficiaries to select a particular option box according to state directives. For more information, refer to the MLN Matters Article titled “Correction CR—Advance Beneficiary Notice of Noncoverage (ABN), Form CMSÙR131” on the CMS website.)
Note: When notifiers issue the ABN as a voluntary notice, the beneficiary does not need to check an option box or sign and date the notice.
Option 1: The beneficiary wants to receive the items or services listed and accepts financial responsibility if Medicare does not pay. He/she agrees to pay now, if required.
Note: Notifiers must submit a claim to Medicare that will result in a payment decision the beneficiary can appeal. If the beneficiary needs a Medicare claim denial for a secondary insurance plan to cover the service, notifiers may advise the beneficiary to select Option 1.
Option 2: The beneficiary wants to receive the item or service listed and accepts financial responsibility. He/she agrees to pay now, if required. When the beneficiary chooses this option, notifiers do not file a claim, and there are no appeal rights.
Note: Notifiers will not violate mandatory claims submission rules under Section 1848 of the Social Security Act when they do not submit a claim to Medicare at the beneficiary’s written request.
Option 3: The beneficiary does not want the care in question and cannot be charged for any items or services listed. Notifiers do not file a claim, and there are no appeal rights.
H. Additional Information: Notifiers may use this space to provide additional clarification or information that may be useful to the beneficiary. For example,
- a statement advising the beneficiary to notify his/her healthcare provider about certain tests ordered but not received,
- information about other insurance coverage, such as a Medigap policy, if applicable,
- an additional dated witness signature,
- identification of the billing provider if more than 1 is listed in the Notifier section A, or
- other necessary annotations.
Medicare assumes the notifier made annotations on the same date as that appearing with the beneficiary’s signature unless the notifier includes a separate date with the annotation.
If a beneficiary refuses to choose an option box and/or sign the notice when the ABN issuance is required, document the refusal in this section.
I. Signature: The beneficiary, or the beneficiary’s representative, signs the ABN to indicate he/she received the ABN and understands its contents. If a representative signs, he/she should write out “representative” in parentheses after his/her signature and print the name if it is not legible.
J. Date: The beneficiary, or the beneficiary’s representative, writes the date he/she signed the ABN. If the beneficiary has difficulty writing and requests assistance in completing this box, the notifier may insert the date.
Disclosure Statement: The disclosure statements in the footer of the ABN must be included on the document.
For further information about ABNs, refer to Chapter 30, Section 50 of the Medicare Claims Processing Manual, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912.html.