A Medicare beneficiary’s ability to have options and to make financially informed choices about his or her health care is essential. Advanced Beneficiary Notices of Non-Coverage (ABNs) play an important role in making sure beneficiaries understand their financial responsibilities for medical items and services that Original Medicare (i.e., fee-for-service) is expected to deny. In addition, ABNs serve to protect the rights of providers and suppliers (including physicians, other practitioners, independent laboratories, home health agencies, and hospices) to pursue payment from a beneficiary where Medicare does in fact deny payment.
The Centers for Medicare & Medicaid Services (CMS) may deny payment for different reasons, including but not limited to those items or services that are not found to be medically reasonable and necessary, are covered personalized-prevention plan services performed more frequently than coverage guidelines allow, or that are determined to be experimental, etc. CMS recently released an updated version of its ABN form, which is intended to help beneficiaries better understand the financial implications of their health care choices.
The updated form, which is currently valid through March 31, 2029:
- notifies beneficiaries beforehand that certain items, tests, services or care will likely be denied; and
- shifts potential financial liability for such to beneficiaries. Beneficiaries then have the option to:
- get the item, test, service, or care listed on the ABN and have Medicare billed for an official decision on payment;
- get the item, test, service or care, listed on the ABN without billing Medicare; or
- decline the item, test, service, or care listed on the ABN.
The updated ABN form also explains who is financially responsible in each of the above-referenced situations. It is important that providers and suppliers keep signed and dated ABNs in beneficiaries’ medical records and provide copies of the same to beneficiaries, if requested.
The updated form is available in English and Spanish, as well as in accessible formats with detailed instructions here. A specific form for laboratory services can also be found using the same link.
While providers and suppliers are allowed to use the prior version of the ABN form until May 12, 2026, starting the transition to using the updated ABN form now is a medical records documentation “best practice”, which also may pay dividends in a future audit, review, or investigation. While the use of ABNs is not required in all cases (e.g., services not typically covered by the Medicare program), CMS recommends that providers and suppliers provide ABNs to beneficiaries as a “courtesy” to educate them about their payment responsibilities.
Should you have any questions regarding the above or other compliance “best practices”, please contact the authors, the Garfunkel Wild attorney with whom you regularly work, or contact us at [email protected].
