Billing: Don't fall for misconceptions

Q. As our company is executing more non-assigned claims, ABNs are being utilized more frequently. Are ABNs required for non-assigned claims?
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Tuesday, June 26, 2018

A. The quick answer is maybe. Let’s start with some misconceptions in the industry about non-assigned claims. 

One of the misconceptions is that a supplier has no financial liability and to get an ABN with non-assigned claims. Essentially, non-assigned means that the supplier is not accepting the fee schedule amount because the reimbursement is too low. 

The explanation on the ABN for a non-assigned claim cannot be “claim is being submitted as non-assigned.” With a non-assigned claim, there still is financial liability meaning, the supplier needs to make sure the coverage criteria has been met according to the medical policy. If the coverage criteria is not met, this is when an ABN is implemented whether it’s an assigned or non-assigned claim.

The purpose of an ABN is to inform a beneficiary in advance the reason Medicare may not pay for the service being provided. If the reason for denial on the ABN is “claim is non-assigned,” this is not a valid reason and will be denied in an audit. ABNs are used for lack of medical necessity, same/similar equipment, quantity exceeds allowed amount, and upgrades (not within the same code). 

Remember, the ABN speaks to the beneficiary, making sure they understand the information documented on the form. The ABN allows the beneficiary to make an informed consumer decision about whether or not to receive the services for which he or she may have to pay out of pocket or through other insurance. 

ABNs do get audited. If not used properly and completed as instructed, an ABN will cause an unfavorable decision in an audit. Be sure to review the ABN instruction manual with staff.