The ABN: not just about the upgrade

Tuesday, April 30, 2002

LAS VEGAS — The fastest regulatory change coming down the pike shouldn't blind-side suppliers. It's the much-hyped advanced beneficiary notice (ABN), the form advising beneficiaries that Medicare might not cover an item they're purchasing.

Asela Cuervo, senior v.p. and general counsel for AAHomecare, schooled a full house on the ABN during a conference session titled "Regulatory Developments That Affect The Homecare Industry" at Medtrade Spring last month.

Although the upgrade provision of the ABN has "made the biggest splash" to date, Cuervo said the full ABN, which will replace waivers, is expected to receive final clearance from the Office of Management and Budget (OMB) in September. The OMB is slated to give the form's instructions clearance at that time as well, she said.

According to Cuervo, the good news is this: For a little more paperwork, at least in the beginning, suppliers get a form that CMS has instructed the DMERCs they must accept. Moreover, suppliers will now have uniform rules to work from, and they'll be able to use the ABN for assigned and unassigned claims.

To use the ABN successfully, Cuervo said suppliers must provide the form before an item or service is delivered. They must also have it signed by the beneficiary or someone who has the authority to act on his or her behalf, she said.

"That's still a little fuzzy," Cuervo said.

Suppliers must also provide the form even if a beneficiary has secondary insurance, Cuervo said.

Cuervo cautioned suppliers, however, to refrain from using the ABN "routinely." She said the forms should be used on a case-by-case basis when the supplier expects Medicare won't pay for an item.

"You can't give out ABNs for all items," Cuervo said. "Just because a beneficiary might want to pay cash, you can't give them an ABN and wash your hands of the transaction. You have to make an effort to get a CMN [certificate of medical necessity]."

Cuervo said AAHomecare lobbied to have that changed, claiming it was duplicitous for the supplier, but CMS wouldn't budge.

Cuervo also cautioned suppliers to refrain from submitting generic reasons for filing an ABN, i.e. "Medicare always seems to deny claims for walkers."

In other regulatory news, Cuervo said it looks like changes to streamline the appeals process, which was mandated by the Benefits Improvement and Protection Act (BIPA) of 2000, will be delayed another year. The changes were due to go into effect in October, but CMS, which has fought the mandate "tooth and nail," claims there's no money in the president's budget to make the changes, Cuervo said. CMS would like to hire a separate set of contractors (from the DMERCs) to handle appeals, including those for coverage. HME