Make sure patients understand ABNs

Can you determine if a notice is valid?

Medicare requires physicians to give beneficiaries an Advance Beneficiary Notice (ABN) to read and sign when physicians believe that Medicare will not cover a service they are about to provide or that Medicare will consider the service to be "medically unnecessary." If you do not provide the patient with a "timely" ABN and the carrier denies the claim, you may have to give the patient a refund. "Timely" is defined as far enough in advance of receiving the medical service that the patient has enough time to make a rational, informed decision.

Don’t wait until they’re strapped to the table

The ABN should ideally be handed to the patient, preferably while he or she is in the office. Telephone calls informing a patient that a service may not be covered are not considered adequate notice because they cannot be verified. Other examples of situations that are not considered adequate notice include when the patient is connected to a testing device or on the table for an MRI, because this kind of last-minute notice is considered to be coercive, regardless of your intentions.

If you do not use the standard government-issued ABN form, you must be sure to explain why you expect that Medicare may deny payment so the patient can make an informed decision about whether to go ahead with the service and pay for it out of pocket. A routine statement to the effect that you can never be sure when Medicare might deny a claim is considered insufficient. Also, Medicare frowns on routinely giving out ABNs for all claims and services.

A patient must be able to comprehend the ABN for it to be legal. A patient is considered unable to understand the ABN if he or she is:

  • comatose;
  • confused, i.e., experiencing confusion due to senility, dementia, Alzheimer’s disease, etc.;
  • declared legally incompetent, under great duress, or in a medical emergency;
  • unable to read the language in which the notice is written;
  • blind or visually impaired and cannot see the words on the printed page;
  • deaf and cannot hear an oral notice;
  • unable to speak to ask questions about the printed form without help of a translator.

In such situations, a relative or other legally authorized person may sign the form on the patient’s behalf. If that is not possible, you could have forms printed in another language; have someone read the form to the patient in his or her native language; have the form printed in extra-large letters or Braille; or get a sign-language interpreter to translate the form.

If the patient or the person acting on the patient’s behalf decides not to sign the ABN, you should make a note on the form indicating the circumstances and persons involved in the decision. In such cases, you may decide not to furnish these services to the patient because the patient has not agreed to be personally liable should Medicare deny the claim.

Even when a patient signs the ABN, you should still submit the claim to Medicare. But first, ask the carrier if they want you to submit the ABN with the form or simply indicate on the claim form that an ABN exists.

Once Medicare denies the claim, you can bill and collect from the patient.