Use ABNs, don't get 'punked' on audits

ATLANTA - With the elimination of Medicare's least costly alternative option earlier this year, CMS is now denying claims instead of downcoding them. This development makes the advanced beneficiary notice (ABN) option more critical than ever for HME providers, says consultant Andrea Stark.

"ABNs are a money-making tool in an environment where few exist," Stark, with Columbia, S.C.-based Mira Vista told Medtrade attendees in October. "It can be used to empower consumers to spend more cash."

Since CMS terminated downcoding last February, the agency has been issuing outright denials for claims instead of paying for lower-level items. Numerous categories are affected by this policy change, including manual and power mobility, hospital beds, orthotics, patient lifts, CPAP devices and nebulizers.

Even so, providers can pivot off of claims denials that state an item is "not reasonable and necessary" as a way to trigger the ABN, Stark said. Proper use of the "hardworking" GA and GK modifiers are essential, as are precise, descriptive narratives when required. Language makes a huge difference, she said, and generic statements like "Medicare may or may not cover this item" are not sufficient.

"ABNs are under an audit microscope and providers are getting 'punked' on audits for making vague descriptions," she said.

Providers also need to know what collection recourse they have for beneficiaries who refuse to return products or pay for services. To illustrate, Stark said there are instances where a family won't return a support surface because even though the patient's wound healed--ceasing Medicare coverage--they are afraid the wound will return without it and won't let the HME provider reclaim the product.

"And they won't pay the $400 to $500 a month for the support surface, so what can you do?" she said.

For those who accepted assignment on the patient, providing an annotation that shows the patient wanted the product or service but refused to pay should effectively "transfer liability from the provider to the patient," Stark said.