In the wake of new market pressures, upgrades, non-assigned claims and cash sales are taking center stage. The market has changed and your business should contemplate the suitability of these options, but they are not appropriate in all cases. This is the fourth article in a four part mini-series to break down the top myths of filing non-assigned claims and leveraging upgrades and cash sales. Below you will find the fourth myth in the series:
Myth #4: An Advance Beneficiary Notice (ABN) must always be executed before a claim can be filed non-assigned.
Myth #4: An Advance Beneficiary Notice (ABN) must always be executed before a claim can be filed non-assigned.
This is FALSE.
If you expect the claim to pay, the ABN form is not appropriate. The ABN should only be executed 1) when the beneficiary is requesting that you do NOT file to Medicare, or 2) when you expect Medicare to deny the claim for medical necessity reasons. It is not a routine requirement for filing non-assigned absent these two reasons.
Refund requirements attach to all non-assigned claims. As such, you must refund all monies collected from a beneficiary when an item denies for medical necessity reasons and the beneficiary was not informed, prior to receiving the service, why Medicare would not pay for the service in this circumstance. Therefore, prior to delivery, documentation should be screened for medical necessity on all non-assigned claims.
When a beneficiary waives their right to file a Medicare claim, you should still screen documentation for potential medical necessity vulnerabilities. If there are any concerns, they must be disclosed on the ABN in terms the beneficiary can understand. The beneficiary can revoke their directive to not file a claim at a later date, and this will obligate the supplier to file a claim.The supplier must have previously disclosed the medical necessity concerns to avoid having to refund monies upon claim adjudication.
Do you have a question you want us to cover for this series? Post a comment on our website or email us at info@miravistallc.com with the subject “MythBuster”. Then stay tuned for more myth busting from Andrea Stark and MiraVista.
If you expect the claim to pay, the ABN form is not appropriate. The ABN should only be executed 1) when the beneficiary is requesting that you do NOT file to Medicare, or 2) when you expect Medicare to deny the claim for medical necessity reasons. It is not a routine requirement for filing non-assigned absent these two reasons.
Refund requirements attach to all non-assigned claims. As such, you must refund all monies collected from a beneficiary when an item denies for medical necessity reasons and the beneficiary was not informed, prior to receiving the service, why Medicare would not pay for the service in this circumstance. Therefore, prior to delivery, documentation should be screened for medical necessity on all non-assigned claims.
When a beneficiary waives their right to file a Medicare claim, you should still screen documentation for potential medical necessity vulnerabilities. If there are any concerns, they must be disclosed on the ABN in terms the beneficiary can understand. The beneficiary can revoke their directive to not file a claim at a later date, and this will obligate the supplier to file a claim.The supplier must have previously disclosed the medical necessity concerns to avoid having to refund monies upon claim adjudication.
Do you have a question you want us to cover for this series? Post a comment on our website or email us at info@miravistallc.com with the subject “MythBuster”. Then stay tuned for more myth busting from Andrea Stark and MiraVista.
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