I post this question because so many people I speak with are totally unfamiliar to this very important piece of paper. Nearly three years ago my husband was told he needed a PET Scan....he checked with both his Oncologist and the hospital to sure this would be covered. He also contacted Medicare and was informed pre-approvals were not necessary. Since he has never had issues with the multitude of scans he had previously he didn’t question further. When he was on the table fully prepared for the scan, someone came in and he was told he had to sign a Medicare waiver. They simply explained there was a possibility Medicare would not pay. Since he was assured he was covered, he signed. Medicare refused to pay the 10K bill. We thought it might have been a coding error. He disputed with all necessary paper work (Oncologist report, etc) and Medicare still declined. Now he’s almost a year into this and the hospital referred the bill to a collection agency.
After days of continual research I came across the ABN (Adavanced Benificiary Notification). All medical providers, hospitals, labs, physicians, nursing homes etc. MUST provide this form if they feel Medicare won’t pay. Not a generalized waiver, but the form provided by CMS. This form stipulates a dollar amount that must be filled in and an explanation to the patient as to why this may not be covered. Also, it must be presented in advance so the patient can make an informed decision. Medicare typically won’t volunteer the information about the ABN....you have to dig, and dig....and after that hope you get a well schooled agent to tell you how to move forward.
Once again he disputed the claim saying he never signed the ABN and after Medicare investigating this we were informed that the claim was still denied but the hospital had to absorb the cost. The hospital still insisted we were responsible....and after contacting Medicare again.....they reminded the hospital they were in violation of contractual agreement. Our account now has a zero balance.
The health field that accepts Medicare are all well aware of this, but the patient is not and it seems it’s a well guarded secret. This happened at a top rated hospital, so consumer beware.....the ramifications can be devastating. I hope this two year journey helps someone in a similar situation.
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ABN only applies to standard Fee-for-service Medicare (not Medicare Advantage plans or Part D drug plans).
There are specific rules and regulations about requiring a patient to sign an ABN.
1. "Health care providers/suppliers are prohibited from issuing ABNs on a routine basis (i.e., where there is no reasonable basis for Medicare to not cover). Providers and suppliers must be sure that there is a reasonable basis for non-coverage associated with issuance of each ABN." (providers do it anyway. I have reported several violators of this rule to Medicare. If you report, they will likely refuse to treat you in the future.)
2. "If an ABN is not issued or found to be an invalid notice in a situation where notice is required, provider/supplier is not permitted to bill beneficiary for services and provider supplier may be held liable if Medicare does not cover."
3. "After beneficiary signs a properly issued ABN indicating his/her choice to receive item or service and accept financial liability, provider/supplier is permitted to bill beneficiary for care."
4. "It is inappropriate to produce an ABN for all Medicare beneficiaries receiving services for every procedure or office visit."
5, The ABN must be signed BEFORE care is provided. Providers cannot ask ABN to be signed AFTER the care or AFTER Medicare denial of payment.
Non-coverage situations ("triggering events"):
1. The test/treatment is deemed not medically necessary or reasonable in patient's specific situation. The doctor must provide a specific diagnosis/symptom code to justify necessity. (If code not provided, you will be asked to sign ABN. Get your doctor to provide medical justification before proceeding.)
2. Medicare has limits on the number of times a test/treatment can be done within specific time period. If doing the test/treatment would exceed the limitation, it is not covered. (example: screening mammogram is covered once per year. If you already had one and decide to have another one done "just in case because a friend/relative was just diagnosed with breast cancer", Medicare will not pay for second screening mammogram that year.)
3. Test/treatment considered experimental.
4. Care is considered custodial and not medical care.
My experience with ABNs in relation to limitation numbers: Even though I know I haven't had the test done at all this time period and tell provider so, they will say they have no way of knowing if that is true and will ask me to sign ABN. Save yourself the stress and sign the ABN. You know the truth and Medicare will pay.
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I did receive something like this from LabCorp and an explanation. My doctor's office used the wrong code. It eventually got paid.
Just a heads up. Check your credit scores. The Hospital may have wrote it off but the information doesn't always get to the collection agency.