Advance Beneficiary Notice Advice for Patients

How to Explain the Advance Beneficiary Notice

Do you know how to explain the Advance Beneficiary Notice (ABN) to patients? It’s critical that chiropractors and their teams present and explain the ABN to patients prior to any service or procedure when it’s expected that Medicare won’t pay. Because the language of the ABN might be confusing to some beneficiaries, you need to make sure you’ve explained simply but thoroughly, and that they understand the ABN’s intended purpose and meaning. Encourage and allow the patient to ask questions and review all of their options with them so that they can make an informed decision.

The patient should know that by signing the ABN, they’ll be responsible for the payment. You must also explain to them that they can refuse the recommended service/procedure, an action that will protect them from any financial liability. Note: only the patient or their representative can make the decision to accept or refuse the service/procedure. No matter how helpful you might be trying to be, you must say nothing that could be construed as coercion, undue influence, or even a friendly suggestion.

Once the patient has signed the ABN form, be sure to give them a copy and keep the original in your paper or electronic health record.

The ABN form may come up in several different scenarios. You should create sample ABN templates for each, and each should be filled in accordingly for each scenario.

  • The patient has completed an episode of care, and further treatment for this same condition is likely to be deemed maintenance care.
  • Your Medicare carrier has a published screen by diagnosis, a rolling 12-month year, or monthly maximum, and the patient has reached that number, calling into question whether Medicare would continue to pay for this condition. Further treatment for this condition will probably not be covered.
  • The patient has been seen more than one time in a day, and two visits in the same day are never covered.

Here’s a sample script of how your conversation could go. This is for example only, and should be customized for your practice:

“OK, Mrs. Jones, as Dr. Smith mentioned, we have reason to believe that Medicare will not pay for (ongoing care, second visit in the same day, continued care for the same diagnosis) for your (insert condition being treated here) since Medicare will only continue to cover your services when Dr. Smith can document ‘significant improvement in your function.’ At this time, any additional care for (insert condition here) will likely be denied by Medicare, and they expect you to cover the cost of your adjustments.

“This form is your acknowledgement that you understand what we’ve just reviewed, and that you’re electing to continue with the (maintenance care, visits beyond the allowable, second visit in the same day) and understand you will probably have to pay for the service yourself. (Point to the range of fees in the right-hand box of the ABN form.) The fee for the adjustments will range from ______ to ______ depending on how many areas the doctor treats.

“Your only decision to make at this time is one of these three options:

“By checking Option One, you indicate that you’d like to have the (maintenance care, visits beyond the allowable, second visit in the same day) and that you’d like us to go ahead and bill it in order to get a denial from Medicare. This is even though we know they will not cover it based on the way it will be submitted. It will still require that you get paperwork at home, etc. but if you want us to, we’ll submit it. If you choose this option, we could appeal a denial if necessary.

“By checking Option Two, you indicate that you’d like to have the (maintenance care, visits beyond the allowable, second visit in the same day) and you’re directing us not to bother billing it. This way, we don’t have to bill them or have them send denial notices to you at home, and there’s nothing for you to keep track of. But this option would also waive any appeal rights we have. Again, we don’t expect this to be covered anyway.

“Finally, by checking Option Three, you indicate that you’re not going to proceed with the (maintenance care, visits beyond the allowable, second visit in the same day) at this time. Which option is best for you, Mrs. Jones?”

If the patient decides that they don’t want the ongoing care and a team member is completing this step, rather than the doctor, be sure that the doctor speaks to the patient at that time to properly document the patient’s choice in their file. Once you’ve explained all three options, always ask the patient if they have any additional questions. Make a copy, and give the copy to the patient.

If a patient signs the ABN and they later decide they want to change their option choice, you need to present the previously completed ABN to them and ask that they annotate it. The annotation must include a clear indication of his or her new option selection, along with the beneficiary’s signature and date of annotation. In situations where the notifier is unable to present the ABN to the beneficiary in person, the notifier may annotate the form to reflect the beneficiary’s new choice and immediately forward a copy of the annotated notice to the beneficiary to sign, date, and return.

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