image image

What is ABN?

ABN is the abbreviated form for Advanced Beneficiary Notice of Noncoverage. It is a waiver notice that your provider must give you before you receive service under Medicare.

This waiver is based on the Medicare coverage rules and if your provider believes that the service you are about to receive will not be covered by Medicare, they need to inform you about it. 

People who have Original Medicare are the people who receive ABN, people covered under Medicare Advantage Plan will not receive one. ABNs depend on the provider who is giving it out. The look differs from one provider to the other.

ABN allows you to decide if you will go ahead to access the service even if Medicare does not cover it. The ABN also allows you to take financial responsibility for the service you are getting if Medicare does not pay for it.

You can decide to pay out-of-pocket of pocket or use existing insurance to pay. An ABN must explain the reason why the health care provider believes that Medicare will not pay for the service you have received.

Although the health care provider believes Medicare will not pay for the service, that is not always the case. You must first sign the ABN to access the service and the wait for a response from Medicare.

Sometimes, Medicare ends up paying for the service if claims are submitted. You should indicate that the health facility should bill Medicare first before billing you. If Medicare ends up paying then you do not need to pay.

Examples of services that are covered by ABN include a visual field examination from an ophthalmologist, an echocardiogram, and a pelvic exam for a primary care provider. These services should, however, be covered if required.

Why is ABN Important

ABN helps to decide the party that is responsible for the payment of the service. The healthcare provider cannot take the financial responsibility for the service they have offered. For the sake of reimbursement, the ABN needs to be signed. If it is not signed, the provider cannot provide the services.

Healthcare providers issue ABNs for a number of reasons. Generally, if they believe that the service is medically unreasonable or unnecessary.

They can also issue it if they are of the opinion that the service is not safe, effective, or not part of the patient’s diagnosis.

Another reason is when the provider has already exceeded the number of services Medicare allows for a specific period of time for a diagnosis.

ABN also protects patients from unexpected financial responsibility. Once the patient signs the ABN, he or she is prepared to make payments even if Medicare does not make payments. ABN also allows patients to appeal to Medicare’s decisions.

When Do ABNs Not Apply?

ABNs are not provided for services that were originally excluded from Medicare. An example of this service is a refractive eye exam.

Patients who are not enrolled in Medicare are also not provided with ABNs. Only patients who are directly enrolled with Medicare receive ABNs.

Patients who have coverage for Medicare produce under a private health insurance company are not included.

Completing An ABN

You can find an ABN on Medicare’s website. When completing one, some fields need to be properly completed for the ABN to be valid. The form should be a one paged document that can be easily read.

The ABN can be sent via email, fax, or mail as long as it follows HIPAA policies. Although the form can be completed and signed electronically, a hard copy should be provided when requested.

The ABN should be kept for five years counting from the date on which the patient signed it. There should also be records of instances where the patient refused to sign the ABN.

The ABN will request for the following information:
1. The name, address, and telephone number of the health care provider.
2. The patient’s name
3. The identification number
5. A description of the service that the health care provider believes will not be covered by Medicare
6. The estimated cost of the service

The patient will then be asked between three options. The first option is that they accept financial responsibility for the service, however, Medicare should be billed first. If Medicare’s decision indicates that they will not pay for the service, they will pay. However, the facility should bill Medicare first to know their decision before billing the patient.

The second option says that the patient will accept the service and take full financial responsibility for it. In this case, Medicare will not be billed at all.

The third option is that the patient does not receive the service at all. This also means that they cannot appeal to see if Medicare will pay for the service.

7. Additional information is any
8. Signature of the patient
9. Date

ABNs and Appeals

If the ABN you signed does not follow the rules given by Medicare, you can appeal to Medicare’s decisions when they do not pay for your health care service. If you are able to appeal and succeed, you will not be responsible for the cost of the service.

You can only appeal when you receive Medicare’s Summary Notice (MSN) which indicates that they decided not to pay for the service you received. You should also verify that Medicare was billed in the first place.

Here are circumstances under which you will not be responsible for the charges that were denied by Medicare.

If the ABN is difficult to read.

If the care provider does not state a specific reason why Medicare may deny payments for the service.

If the ABN does not indicate the actual service provided by the healthcare provider.

If the ABN is given to you during an emergency situation or right before treatment.

If you did not receive an ABN prior the receiving the service.

What Happens When a Patient Refuses to Sign the ABN?

If a patient does not want to sign the ABN, it is important to document it. You will next need to access the service. If denying the patient the service will put his or her life at risk, you will need to go ahead to offer the service. If not, it will be better not to offer the service.