A patient is waiting for a clinical service, probably already with some degree of anxiety. At this point, few things are less welcome than the dreaded Advance Beneficiary Notice (ABN). The form asks patients to accept financial responsibility for the entire cost of the service if Medicare denies payment.
When the registrar asks the patient to sign it, acknowledging they may be paying for the service out of pocket, a blank look (or worse) typically follows. “Patients don’t just show up at a hospital asking for services that aren’t medically necessary. Their physicians send them,” says Kevin Willis, director of Medicare services at Claim Services, an Aurora, IL-based claims adjusting company.
Upon learning that the scheduled service might not be covered, the patient typically will ask many questions. Some refuse to sign the forms, while others feel the need to call their health plan immediately.
“We have physicians ordering things that aren’t covered, but we expect patients and/or the facilities to know when that’s not right,” Willis notes.
If Medicare denies the claim, the hospital is left with two bad choices. Neither is patient-friendly, and both are problematic for the revenue cycle. “Either the facility must tell the patient that their physician is wrong — never good — or the facility has to eat a bill for a service they didn’t order, which is completely unfair,” Willis explains.
At Lewes, DE-based Beebe Healthcare, patient access has confronted the troublesome ABNs directly.
“We have done a lot of work with our ambulatory provider offices to ensure they understand the process and reason behind ABNs,” says Maurice Winkfield, director of patient access.
In turn, the offices educate patients. This is especially important at Beebe Healthcare due to the hospital’s large Medicare population. “You want to make sure patients fully understand the ABN form if they are being asked to sign it and make decisions that may affect their wallet,” Winkfield offers.
At Slidell, LA-based Ochsner Health, a major change was made in how ABNs are handled. “We really have removed ourselves from this process,” says Tanya Powell, CHAM, patient access director of the health system’s Northshore and Hancock regions.
Now, ABNs are completed by the clinical teams at the time the service is ordered. Previously, patient access handled the ABNs as part of the registration process. At the time the order is placed, a pop-up box appears in the registration system.
“It prompts us to review the diagnoses or activate the waiver form for the patient signature,” Powell says.
When the appointment is scheduled, a prompt is shown stating that the CPT is not covered. Most helpfully, it also shows the associated diagnosis. Patient access then goes straight to the source: the Centers for Medicare & Medicaid Services website. “We then understand why the diagnosis does not work,” Powell adds.
Lastly, patient access looks up the local coverage determination. This piece of information allows them to pay the claim to the benefit of both the patient and the hospital. “We can see what the documentation requires in order for the diagnosis to qualify,” Powell explains.