Understanding Medicare: Advance Beneficiary Notice (ABN) of Non-Coverage

https://www.youtube.com/watch?v=8_PpCr973ZI

In this article, we'll dig into how ABNs work, and how Micro-Dyn may be able to help your revenue processing handle them.

❓ What's An Advanced Beneficiary Notice?

In hospital billing, Medicare may not cover some costs. When costs aren't covered by Medicare, someone still needs to pay them! However, patients also need advance notice that their Medicare won't cover services. That's when a medicare beneficiary receives an ABN, or an advanced beneficiary notice of non-coverage. The ABN serves as a written reminder that an item or service will likely not be covered by Medicare. An ABN may also outright inform a patient that the service is never covered by Medicare. This form will list all items or services unlikely to be covered, along with their out-of-pocket cost.

📝 How do ABNs work?

An ABN form must be delivered to the Medicare beneficiary by a provider before the services or items are given. ABNs are issued when a service is deemed "not reasonable and necessary". They may be issued because the service is a routine exclusion, is experimental, or exceeds the frequency of services allowed in a time period. The form will also list the reason Medicare is likely to deny payment. The ABN allows the patient to make an informed decision about continuing with the service and paying out of pocket or declining the uncovered service. The provider in question could be a physician, hospice provider, outpatient hospital, home health agency, or medicare inpatient facility. When a notifier issues an ABN, they must review it with their patient or their representative. This delivery and review must happen far enough in advance that the patient can reasonably consider their decision to purchase the service. The provider also needs to sign the ABN prior to the date the service is provided.

🚨 Is an ABN always required?

In the event of an emergency, ABNs are not required. This is because federal policy states that they can't be given to a patient who is "under duress,", ie a patient rushing to receive care in an emergency. This helps prevent patients from making financial decisions when unstable or under extreme stress.

⚠️ How can ABNs be difficult to process at scale?

When the ABN is filed incorrectly, the patient can then appeal to Medicare to report it. If providers aren't able to issue a timely and correct ABN, and Medicare subsequently denies the claim, the provider cannot then bill the patient. This can mean the providing facility takes a financial loss. When hospital billing departments are struggling to process thousands of claims a month, ABNs can slip through the cracks. Since hospitals cannot issue a valid ABN after the fact, billing teams must recognize necessary ABNs proactively. ABNs require billing departments to know in advance if a service is unlikely to be covered, before a patient receives the procedure. Knowing in advance if Medicare is likely to deny a claim requires understanding of:

• Medicare's Prospective Payment System (PPS) rules across multiple care settings

• Current reimbursement rates and coverage logic

• How diagnosis and procedure coding interact with payment and coverage

  
  

  When billing departments rely on outdated tools or manual workflows, these processes can break down, leaving a facility with outdated ABNs. If these ABNs are appealed, the facility loses revenue.
  

💸 What happens when an ABN isn't issued correctly?

ABNs must be current, complete, and understood by the patient before services are provided. Facilities receive two types of consequences from an incorrect ABN: financial and compliance.

• Financial Consequences: Not sending a correct ABN for a later denied claim means that the facility must eat the cost of the procedure. Even a few missed ABNs can result in thousands of dollars in lost revenue. These missing pieces can really add up.
  

• Compliance Consequences: If an ABN is issued incorrectly (with an incorrect form, inadequate notice, or missing information), the ABN can be rendered invalid. CMS has specific rules for ABN language, timing, and delivery. ABNs also can't be used to get payment if the facility is relying on messy or incorrect healthcare coding.
  

CMS regularly revises the ABN, requiring healthcare facilities to be active about staying current. When a new ABN is introduced, older ones are no longer accepted as valid after a certain point 🛠️ How Can Micro-Dyn Help with Notice of Noncoverage Processing?

Micro-Dyn's claims pricing and repricing tools can help keep ABNs compliant with accurate claims pricing rules. Great pricing tools are vital in making sure your ABNs are timely and accurate to ever-changing CMS rulings. Micro-Dyn keeps up with CMS rules, helping your team function with another source of truth. Strong claims pricing tools like Micro-Dyn can also catch denials before they happen by flagging items that don't meet Medicare rules. These items that don't meet Medicare rules are also often the ones that trigger an ABN. Micro-Dyn also provides accurate Medicare pricing, making sure your team understands coverage before the patient is seen. Try Micro-Dyn for Better ABN Processing Today