Executing ABNs: When a Patient Refuses to Sign

Executing compliant Advanced Beneficiary Notices (ABNs) can be tricky. ABNs are particularly troublesome when you encounter a beneficiary that refuses to sign and accept financial responsibility. In these cases you should generally refuse service to the patient. But what if that is not a viable option? Perhaps the health of the patient would be put in jeopardy if you refuse service or what if the patient already has the equipment and now refuses to sign? In these cases, it may be possible to execute an ABN even if the patient refuses to sign, as long as certain requirements are met.

In order to effectively execute an ABN in instances when the patient refuses to sign, ALL of the following conditions must be met (no exceptions):...

• You must accept assignment on the claim.
• Your ABN must include the specific reason(s) the claim is expected to deny.
• The patient must have demanded the service, but still refused to sign the ABN or be held financially liable.
• The patient’s refusal to sign must be witnessed by the notifier (you) and a second party (this can be over the telephone where the second party is called to witness the refusal while you are on-site).

These requirements are outlined by CMS in Chapter 30 of the Claims Processing Manual (http://146.123.140.205/manuals/downloads/clm104c30.pdf); Section 40.3.4.6 discusses Beneficiary Refusal, Section 50.13.2 Discusses the Refund Requirements applicable to DME providers, and Section 150 further details the implementation of the Refund Requirements on DME claims.

If, and only if, the above requirements have been met are you able to proceed. Be sure to include an annotation on the ABN stating that the patient refused to sign or take financial liability, but still demanded service. This should be signed by both the notifier (you) and the second witness. The notation can be included above the empty patient signature line or in the margins of the ABN. When filing your claim, utilize the GA modifier to indicate that the ABN was presented to the patient. If executed properly, Medicare will hold the patient financially liable for the claim.

We recommend that you send a copy of the notice to the beneficiary along with a notice that they will continue to accrue monthly liability on the equipment up until the date the equipment is returned.  They may return the equipment at any time to avoid future monthly payments.  The customer remains responsible for any monthly payments accrued while the equipment remained in their possession.