Most practices know the ropes of using an Advance Beneficiary Notice (ABN) of Non-Coverage: When a service might be denied and you want Medicare patients to understand what their financial responsibility may be, you have them sign the ABN. But what happens when you see a patient who has Medicare Advantage rather than a Part B policy? Does the ABN form still apply? This is where things may get tricky.
CMS specifically states that ABNs apply to patients enrolled in Medicare Fee-for-Service programs, and not for items or services provided under Medicare Advantage (MA). This means that when you are advising a patient about a potentially non-covered item or service, you must follow each individual Advantage payer’s guidelines.
The following key points can help you understand what to do instead of using an ABN form for Medicare Advantage patients.
Some Payers Have Specific Non-Coverage Rules
In certain cases, MA payers will come out and say how they want you to proceed before you charge patients for non-covered services.
For instance, if your patients are covered under Aetna’s MA plan, you have two options if you want to collect from patients for services that the program won’t reimburse:
- You can collect from patients if the item or service is never covered under Original Medicare (such as cosmetic surgery).
- You’ll be able to bill patients if Aetna has sent the patient a preservice Organization Determination (OD) notice from Aetna.
The first option is fairly self-explanatory. For the second, this means that you have to call the Aetna MA plan ahead of time and give them the codes you plan to bill and the amount you’ll charge. They then will send the patient an OD notice essentially saying “We’re not going to cover this. You have to pay for it at the doctor’s office if you want it.”
If your patient is instead covered under United Healthcare’s MA program, you’ll need to request a prior authorization if you know or have reason to believe that a service or item for a Medicare Advantage member may not be covered. The payer will then issue an Integrated Denial Notice (IDN) telling the patient what their cost for the non-covered service or item would be.
Once UHC issues the IDN, you can bill the patient for the service, and then you’ll submit the claim with modifier GA appended to the appropriate code. UHC will then process the claim as a member liability.
If you forget to put the GA modifier on your claim, the insurance company will likely send an explanation of benefits (EOB) to the patient essentially saying, “We see you weren’t notified up front. These services weren’t covered, so you don’t have to pay for them.” You can then submit a corrected claim with GA modifier, but in the meantime, you won’t be able to collect from the patient for the item or service.
When MA Payers Aren’t Explicit, Check These Steps
Not every MA payer will have rules in writing about how to collect from patients for non-covered services in lieu of using an ABN form. In these cases, consider taking these actions:
- Check your original MA contract to determine whether the steps you should take are outlined in writing.
- If you don’t have written guidance from your MA payer, call your provider relations contact and ask for information.
- If the provider relations rep. has guidance about charging MA patients for non-covered services, ask them to send it to you in writing. In the meantime, record their name and what they told you to do.
- Once you get the guidance in writing, distribute it throughout your office and keep it in a safe place so your team knows how to proceed when faced with non-payable services for MA patients.
For more information on how ABNs impact your reimbursement and how to complete them properly, check out the online training session, “Get Paid More for Commercial Payer Non-Covered Services,” presented by Dawn R. Cloud, CPC, CMSCS, CHCI, CPDM. During her 60-minute session, Dawn will walk you through the key steps to help you master all of the ABN steps and regulations.
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