advanced beneficiary notice - Life After 50 Expo

Dear Marci,

I have Original Medicare. My doctor said that she does not believe that Medicare will cover a certain procedure, and that she would like me to sign an Advance Beneficiary Notice. What does this mean, and what should I do?

-Jesse (Austin, TX)

Dear Jesse,

An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the services. The ABN may look different, depending on the type of provider who gives it to you. An ABN is not an official Medicare coverage decision.

The ABN allows you to decide whether to get the care in question and accept financial responsibility for the service (pay for the service out-of-pocket) if Medicare denies payment. The notice must explain why the provider believes Medicare will deny payment. For example, an ABN might say, “Medicare only pays for this test once every three years.” Providers are not required to give you an ABN for services or items are never covered by Medicare, such as hearing aids. Note that our providers are not permitted to give an ABN all the time, or to have a blanket ABN policy.

If you receive an ABN from your provider, there are a few things you should ask before choosing whether to sign the ABN or refuse care:

If your provider things the service is medically necessary, ask why you need to sign an ABN. Medicare should pay for most medical services you need, unless the service is specifically excluded from coverage, in which case an ABN is not required.
Ask your provider if they are willing to help you appeal Medicare’s coverage decision, if the service is denied, by writing a letter justifying your medical nee for the service. If your provider refuses to write a letter or help you appeal, you may want to find a different provider.

While the ABN serves as a warning that Medicare may not pay for the care your provider recommends, it is possible that Medicare will pay for the service. To get an official decision from Medicare, you must first sign the ABN, agreeing to pay if Medicare does not, and receive the care. Make sure you request that your provider submit a claim to Medicare for the service before billing you. The ABN may have a place from where you can elect this option. Otherwise, your provider is not required to submit the claim, and Medicare will not provide coverage. An ABN is not an official Medicare coverage decision.

Medicare has rules about when you should receive an ABN and how it should look. If these rules are not followed, you may not be responsible for the cost of the care. When your Medicare Summary Notice (MSN) shoes that Medicare has denied payment for a service or item, you can choose to file an appeal.
Remember, receiving an ABN does not prevent you from filing an appeal, as long as the provider submits a claim to Medicare. You can contact your State Health Insurance Assistance Program (SHIP) for more information about the process. If you do not know how to contact your SHIP, you can call 877-839-2675 or visit www.shiptacenter.org.

You may not be responsible for the denied charges if the ABN:

Is difficult to read or hard to understand
Is given by the provider (except a lab) to every patient with no specific reason as to why a claim may be denied
Does not list the actual service provided, or is signed after the date the service was provided
Is given to you during an emergency or is given to you just prior to receiving a service (for instance, immediately before an MRI).

You can contact your Senior Medicare Patrol (SMP) for assistance if you are suspicious of a provider’s handling of the ABN or if you believe you were falsely billed for service. If you don’t know how to contact your SMP, call 877-808-2468 or visit www.smpresource.org.

-Marci

Dear Marci,

I recently went to see my doctor to receive some preventive care screenings, and wanted to get an EKG test. My doctor said that Medicare might not cover this test, and gave me something to sign called an Advance Beneficiary Notice. I’m unsure whether I should sign this notice. What is the purpose of an Advance Beneficiary Notice?

– Charles (Phoenix, AZ)

Dear Charles,

An Advance Beneficiary Notice (ABN) is a notice you should receive when a provider or supplier offers you a service or item that Medicare normally covers but may not cover for you. Know that ABNs only apply to people with Original Medicare; people with Medicare Advantage plans will not receive an ABN.

The ABN must list the reason that your doctor thinks Medicare will not cover the EKG. The notice serves as a warning that Medicare might not pay for your care; it is not an official determination from Medicare about whether or not care is covered. It may still be possible to get Medicare to cover your care if you agree to pay for it if Medicare formally denies payment.

If you receive an ABN but decide to move forward with the item or service, you must select Option 1 on the ABN form. Option 1 says you agree to pay for care in the event Medicare denies coverage. It also requires your provider to submit the bill to Medicare after providing you care. If you do not select Option 1, you will have no chance of Medicare coverage because your provider will not be required to submit the bill to Medicare.

You will know if the service is covered by checking the claim on your Medicare Summary Notice (MSN). An MSN is a summary of the health care services you have received over the past three months, and it describes whether Medicare has covered these services. If the claim is denied, you can appeal by following the directions on the MSN. If the claim is approved, the MSN will say how much you owe. If you paid the provider more than that, the provider must refund you the excess amount.

Keep in mind, by agreeing to get care and signing Option 1 on ABN, you must be willing to pay upfront for care at the time you get it and you risk being responsible for all charges if Medicare denies payment. In some cases, this can amount to a significant bill. If you receive an ABN, be sure to discuss your options for care with your provider.

– Marci