The ins and outs of when to use an advance beneficiary notice is complex, but understanding it is crucial, Tony Mira wrote in a September blog post. Mr Mira laid out the key tips on how anesthesia providers should approach ABNs when Medicare is expected to deny payment.
ABNs are primarily used when the provider predicts the service a patient is looking for will be denied because it lacks "medical necessity," as defined by Medicare guidance, according to Mr. Mira.
There are mandatory and voluntary ABN situations. If a service doesn't meet the Social Security Act's definition of a medical pursuant or is specifically itemized, then an ABN is unnecessary but is encouraged as a courtesy so that patients are aware of the estimated charge.
If service is likely to be denied based on medical necessity, however, then an ABN is mandatory when the provider is proceeding with the service and then billing the patient. General anesthesia, for example, is considered not reasonable for facet joint interventions, so an ABN could be mandatory if the provider is wishing to proceed and get paid by a patient.
Anesthesia providers should go over the page of information on the ABN, which tells the patient if the service will, or is likely to be, denied. The provider cannot decide the billing options for the patient.
If the patient chooses to pay up front but still wants the provider to bill Medicare, and Medicare ends up paying, the provider is obligated to pay back the patient what they paid up front minus the copay and deductible.
It is possible that Medicare may then audit the service, discover a mistake and demand a remittance. At this point, anesthesia providers could go back to get the money from the patients, but the odds of getting paid after the fact are slim.
"Perhaps the better option is to simply avoid performing these specific case types altogether, advising the patient to seek out another provider if they insist on anesthesia in connection with such pain procedures," Mr. Mira said.