Thursday, July 31, 2008

Q. Do ABNs only apply when Medicare is the primary payer?

A. While ABNs are most commonly used when Medicare is the primary payer, they may also be used when Medicare is secondary and/or tertiary. When deciding whether to complete an ABN or not, remember: The ABN’s purpose is to notify a Medicare beneficiary, prior to equipment setup, that Medicare might not cover all or part of the service. Any time you use an ABN for a Medicare primary beneficiary, you should also use it when Medicare is secondary or tertiary if the primary will not pay 100%. If you fail to obtain a signed ABN prior to setup, Medicare will not make payment, and the beneficiary will not be liable for their portion and legally cannot be billed. This amounts to leaving money on the table.

When completing the ABN, the main body of the form must indicate what services are being furnished, the reason why Medicare might not cover the secondary and/or deductible, and the financial estimate for what the patient may be liable for. A sample statement follows: “Medicare may not cover the co-payment on your oxygen equipment because they require your saturation to be 88% or below and your current saturation level is 90%. Therefore, your estimated co-payment will be X% or X dollars per month.” This statement clearly indicates to the beneficiary that there may not be Medicare coverage for co-payments even if the primary insurance approves the charges.

Remember the ABN must be completed and signed by the Medicare beneficiary prior to setup. The claim line item(s) must also be accompanied by the GA modifier. This modifier indicates there is a signed ABN on file and if not present on the claim you will receive an inappropriate denial that will prohibit you from billing the beneficiary.

Lisa Cusick is the corporate consulting manager with Bargmann Management, LLC. Reach her at <a href=