medicare abns (advance beneficiary notices)

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Page 1: Medicare ABNs (Advance Beneficiary Notices)

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

Page 2: Medicare ABNs (Advance Beneficiary Notices)

Medicare ABNs

(Advance Beneficiary Notice)

Page 3: Medicare ABNs (Advance Beneficiary Notices)

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

Page 4: Medicare ABNs (Advance Beneficiary Notices)

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

Page 5: Medicare ABNs (Advance Beneficiary Notices)

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

Page 6: Medicare ABNs (Advance Beneficiary Notices)

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

Page 7: Medicare ABNs (Advance Beneficiary Notices)

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

Page 8: Medicare ABNs (Advance Beneficiary Notices)

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.

Page 9: Medicare ABNs (Advance Beneficiary Notices)

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….

Page 10: Medicare ABNs (Advance Beneficiary Notices)

When (or If) you submitted a claim,

Page 11: Medicare ABNs (Advance Beneficiary Notices)

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.

Page 12: Medicare ABNs (Advance Beneficiary Notices)

If Medicare denies payment

You may collect full charges from the patient.

Page 13: Medicare ABNs (Advance Beneficiary Notices)

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.

Page 14: Medicare ABNs (Advance Beneficiary Notices)

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

Page 15: Medicare ABNs (Advance Beneficiary Notices)

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?

Page 16: Medicare ABNs (Advance Beneficiary Notices)

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.

Page 17: Medicare ABNs (Advance Beneficiary Notices)

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.

Page 18: Medicare ABNs (Advance Beneficiary Notices)

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.

Page 19: Medicare ABNs (Advance Beneficiary Notices)

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.