We all know about the existence of the ABN form, and we all use it to varying degrees. However, the topic does seem to be coming up more frequently as of late. Recently I was asked about using ABNs outside of Medicare as an increasing number of payers have adopted cuts below Medicare rates. However, shifting liability to patients under Medicare HMO plans is not that easy. You effectively have two primary triggers that prompt liability concern with outside payers. The first relates to how to bill deluxe features of a medically necessary base, and the second involves how to invoke protections for services that are not payable by the insurer. To dispel any uncertainty, neither can be accomplished with the use of a traditional Medicare ABN form.
The topic of deluxe features is likely addressed within the bylines of your contract with the payer, or is embedded in online provider manuals and instructions. The first task is to discern the payer’s policy as it relates to deluxe items and how they should be billed. In some cases, providers are instructed to bill an added line as a non-covered service. Others instruct to append certain modifiers. Begin your search for the term “deluxe” while surfing online versions of provider manuals. If you do not find a clear directive, reach out to a provider services representative. This may not be a question they are used to receiving, so be sure to press for an answer that they can put in writing to you.
The other relevant instruction you need to seek guidance on is transferring liability when the beneficiary does not meet coverage guidelines. Historically, HMOs have not accepted Medicare ABN forms, but up until the last few years, many used a variation of the form to pass financial liability to the beneficiary for certain non-covered products. However, in May of 2014, CMS issued a cease order to all Medicare Advantage Plans to immediately stop accepting notices modeled after the Medicare ABN. One such letter was posted to the UHC website.
The topic of deluxe features is likely addressed within the bylines of your contract with the payer, or is embedded in online provider manuals and instructions. The first task is to discern the payer’s policy as it relates to deluxe items and how they should be billed. In some cases, providers are instructed to bill an added line as a non-covered service. Others instruct to append certain modifiers. Begin your search for the term “deluxe” while surfing online versions of provider manuals. If you do not find a clear directive, reach out to a provider services representative. This may not be a question they are used to receiving, so be sure to press for an answer that they can put in writing to you.
The other relevant instruction you need to seek guidance on is transferring liability when the beneficiary does not meet coverage guidelines. Historically, HMOs have not accepted Medicare ABN forms, but up until the last few years, many used a variation of the form to pass financial liability to the beneficiary for certain non-covered products. However, in May of 2014, CMS issued a cease order to all Medicare Advantage Plans to immediately stop accepting notices modeled after the Medicare ABN. One such letter was posted to the UHC website.
Per CMS instruction in the letter, MAOs (Medicare Advantage Organizations) are prohibited from using advance notice-type forms. They must instead utilize the Organization Determination process outlined in the Managed Care Organization Manual in the Code of Federal Regulations Title 42, Chapter IV, Subchapter B, Part 422, Subpart M, Section 422.566. Each MAO is required to have a specific plan outlined for the organization determination process. In this process, providers will be asked to examine services that are expected to be non-covered, submit those service requests to the MAO for review, and receive a specific denial determination via mail…all before rendering the service. This is similar to what providers see now in the Prior Authorization process, except in this scenario the supplier is seeking a denial instead of an authorization.
On the heels of this letter, plans such as United Healthcare began to comply with CMS directives. The UHC protocol is outlined on their website. UHC (like many others) is utilizing a prior-authorization type determination system. Once the request is submitted by the supplier to UHC, and the service is deemed to be non-covered, an Integrated Denial Notice (IDN) will be sent via mail to both the supplier and the plan member. The supplier can only render the non-covered service after the IDN has been received.
As your business model evolves, and as you begin to explore alternative options permitted by your plans, you will need to secure answers to questions like the ones posed here. These answers allow you to evaluate your options, move forward compliantly and service your customers with confidence.
We’ll be answering more ABN related questions and concepts during our event on October 27. If you have an ABN confidence problem, let us give you a necessary boost as we dive in to The ABN: Getting It "Just Right.”
On the heels of this letter, plans such as United Healthcare began to comply with CMS directives. The UHC protocol is outlined on their website. UHC (like many others) is utilizing a prior-authorization type determination system. Once the request is submitted by the supplier to UHC, and the service is deemed to be non-covered, an Integrated Denial Notice (IDN) will be sent via mail to both the supplier and the plan member. The supplier can only render the non-covered service after the IDN has been received.
As your business model evolves, and as you begin to explore alternative options permitted by your plans, you will need to secure answers to questions like the ones posed here. These answers allow you to evaluate your options, move forward compliantly and service your customers with confidence.
We’ll be answering more ABN related questions and concepts during our event on October 27. If you have an ABN confidence problem, let us give you a necessary boost as we dive in to The ABN: Getting It "Just Right.”
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