Patient access using new Medicare noncoverage form

Patients are given more options

Patient access staff will have to get used to a change for Medicare patients, with the new Advance Beneficiary Notice of Noncoverage (ABN) form now used for all situations where Medicare payment is expected to be denied. The form, implemented by the Centers for Medicaid & Medicare Services (CMS), becomes mandatory March 1, 2009.

The revised ABN replaces the existing ABN-G (Form CMS-R-131G) and ABN-L (Form CMS-R-131L). The form also can be used for voluntary notifications in place of the Notice of Exclusion from Medicare Benefits.

This ABN has a new beneficiary option, under which an individual may choose to receive an item or service and pay for it out of pocket, instead of having a claim submitted to Medicare.

"The form has more options for the patient," says Vicki Lyons, patient access manager at Baptist Hospital East in Louisville, KY. Staff tell the patient that compliance has stated that the test will not be covered and ask whether the patient wants Option 1 (they want Medicare billed also), Option 2 (they do not want Medicare billed), or Option 3 (that they do not want the services at all).

"The ABN also now has a phone number for the patient to call if they have any questions, which is nice for the patient," says Lyons.

However, she says that it's often difficult to make the patient understand why Medicare will not pay for a test that they have been told to have by their doctor. "They feel if the doctor has ordered it, than Medicare should pay for it," says Lyons. "So it is challenging to explain this to the patient."

Lyons says that patient access staff are finding that most patients do not want to have the tests if Medicare is not going to pay. "We advise them to call their physicians to make them aware of their decision to not have the procedure," she says.

The only thing that patient access had to do, Lyons says, was to update its compliance software in order to access the new ABN. "Staff were made aware that the form did change somewhat, and that there were more options for them to ask the patient about," she says.

The new form is now included in the hospital's overall training on Medicare Compliance/ABN given to all new hires. "It is part of the many procedures that all the new folks have to learn," says Lyons.

A patient access trainer covers Medicare compliance with the new employees, including review of what tests need compliance. "She also shows them how to enter it into our Medicare compliance software to find out if the order has a covering diagnosis on it," says Lyons. "If the diagnosis does not cover, then we call the physician's office to see if there is another diagnosis that will cover. If there is no covering diagnosis, she will then show them how to print out the ABN for the patient to sign."

First, the trainer shows the staff where to find the list of the Local Medical Review Policies which Medicare requires compliance. "We have this list on our document file on the computer for patient access, so it is very easily accessed," says Lyons.

The trainer prints some patient itineraries out for patients having the tests that need compliance, and the new staff person enters them into the Medicare software. "This way they are getting hands-on training," says Lyons. "If the diagnosis does not comply, then a call is made to the physician's office to obtain additional information."

If patient access staff are having trouble getting a covering diagnosis, they can call coders who work in the hospital's health information management department for assistance. "Since we are not coders, sometimes it can get tricky entering this information and trying to get a covering diagnosis," says Lyons. "The coders have a lot more knowledge on what would be covered and what would not be."

[For more information, contact:

  • Vicki Lyons, patient access manager, Baptist Hospital East, 4000 Kresge Way, Louisville, KY 40207. Phone: (502) 897-8159. E-mail:]