We are often asked if it is ok to either not bill Medicare for a service provided to a patient or to bill the patient instead ? Great questions with a lot of guidelines.
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).
An ABN form is available by CMS at the link attached. The form is subject to public comment and re-approval every 3 years so having the most recent version is very important. There are tutorials, instructions, and forms in both English and Spanish for your use.
The ABN must be reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain a copy of the ABN delivered to the beneficiary on file.
The ABN may also be used to provide notification of financial liability for items or services that Medicare never covers. When the ABN is used in this way, it is not necessary for the beneficiary to choose an option box or sign the notice. CMS has issued detailed instructions on the use of the ABN in its on-line Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, §50 . Related policies on billing and coding of claims, as well as coverage determinations, are found elsewhere in the CMS manual system or CMS website .
On the billing side is a modifier we need to submit with the initial claim to signify the ABN is on file and the patient will then be responsible for the balance - GA Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case Report when you issue a mandatory ABN for a service as required and it is on file. You do not need to submit a copy of the ABN, but you must have it available on request. The –GA modifier is used when both covered and noncovered services appear on an ABN-related claim.
Read the full list of guidelines on the CMS website.
Some states are already making changes to Telehealth coverage. See the new announcement for the State of Florida.
The Administration is taking aggressive actions and exercising regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19). CMS is empowered to take proactive steps through 1135 waivers as well as, where applicable, authority granted under section 1812(f) of the Social Security Act (the Act) and rapidly expand the Administration’s aggressive efforts against COVID-19. As a result, the following blanket waivers are in effect, with a retroactive effective date of March 1, 2020 through the end of the emergency declaration.
From CMS - EXPANSION OF TELEHEALTH WITH 1135 WAIVER: Under this new waiver, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. A range of providers, such as...
Continue reading on CMS
In March of 2020, a long list of waivers were put into effect to help providers contain the spread of COVID-19. These waivers have been in effect since then with 90-day extensions granted now multiple times to cover the time we are still dealing with the effects of the virus. The next one is set to expire on July 19th. Several of these waivers made the way to have Telehealth be a viable option to provide treatment to patients remotely. Some agencies have advocated for a permanent expansion of Telehealth access after COVID-19 and will the individual insurances follow suit?
I have been asked a lot lately if the extensions will expire this next expiration date. That is hard to predict and we can only stay tuned and watch for announcement are made.
Remember, each insurance has their own interpretation and guidelines that they are following and we will have to see what they do. Below are some of the most common payers and their links to the COVID-19 guidelines.
We are often asked to be able to "quote" what the benefits will be for a patient's insurance coverage prior to treatment with a provider. That process has changed dramatically over the years and it is now almost impossible to pin down. Insurance cards sometimes list an office copay benefit but that would only apply to a regular physician's office visit and not any type of specialty, like Psych. On-line access to benefits is an option for some insurances and will usually spell out the regular coverage. Some require a username and password to be set up to be able to go on-line and those also expire every 90-days or so and have to be kept in a secure location for HIPAA requirements. We actually have devoted entire shared, secured documents to just the handling of on-line usernames and passwords.
What does your "pie chart" look like in your practice?
I have used the same practice management software for over 15 years now and one reason I have continued with the same product is the amazing analytics that they provide in the reports module. I can send reports to my providers, daily, weekly or monthly or for any time frame they want and show the details of their practice financials. These reports are to help in seeing their medical practice as the business that it is and to be able to continually monitor the statistics.
There are charge breakdown reports to show which CPT codes are used and those can also be further broken down by locations and insurance. Reports to show where the payments are coming from, which adjustments are made and rendering provider reports that are also sent to CPA's for payroll purposes. It could be anything you could think of that can and should be measured.
As a medical billing/management company, we are given the task to follow up with insurance companies to get the claims paid for any charges turned in to us. Some insurances - like Medicare - make that task easy by having strict regulations in place that we follow and, by doing so, they pay easily and on time. Others will loosely follow guidelines and hold or even deny the same claims, and we are forced to contact them to get that claim paid. Find out how we help get those claims paid.