Properly Executing the Medicare ABN-Part I

Properly Executing the Medicare ABN-Part I

Misunderstood

One of the most misunderstood puzzle pieces of ambulance billing is the Medicare Advance Beneficiary Notice of Noncoverage (ABN).

As we work together with our contracted EMS agency clients, we find that EMS administrators and providers alike are very confused about the when and how to use this form.

As part of a 2-part blog post series, this week we’ll take a look at the form itself, its origins and the theory behind the execution such as when and when not to execute the Medicare ABN.

Next week we’ll explore the actual presentation of the ABN itself, in the field.

What is it?

The form is officially the CMS-R-131 (v.03-11) form which carries and Office of Management and Budget approval number 0938-0566.

So what, you say?

Well, there is importance in those numbers. Namely, it’s the only form used in the field that is mandated to be used as released by the Federal Government. There are specific rules that surround how it can be presented, right down to the font size and specific wording, but especially how it is to be filled out and executed.

The form must be used when mandated and no other “waiver” form is acceptable for a Medicare beneficiary.

When not to use…

Before we begin the discussion about the ABN’s use, let’s first rule out when not to use the ABN.

An ABN CANNOT be used in a 9-1-1/emergency situation. The rules that govern the presentation of this form is prohibited in an emergency setting.

The theory behind this prohibition is that the patient cannot properly comprehend making an informed choice of ambulance providers, nor is there probably an option to use another ambulance company in an “emergency” scenario. Therefore, presenting this form is not allowed in the emergency setting.

ABN use is narrow and limited…

Use of the ABN is very narrow and limited.

Specifically, the ABN is mandatory when the patient could use services at his/her origin facility but is being transported to a second facility anyway as Medicare will not pay for this transport and the patient will be billed for the full cost of the trip.

This basically narrows the use of the ABN to an inter-facility scenario where, for some reason, either the patient or the facility is insisting that the patient be transported from Facility A to Facility B but where the services the patient requires were available at Facility A.

In Theory

The theory behind the ABN is to allow the patient (or a patient representative) to make an informed decision to use your EMS agency, another EMS agency or refuse the transport. Because of this, there are two key parts of executing the form which we will discuss in detail in Part 2 of this blog series…

• Presenting a good-faith estimate of the dollar amount the patient will be billed for the service.
• Presentation of the form and executing it prior to the patient’s being loaded into the ambulance.

Once presented, the form should be explained and then read over carefully by the patient and/or patient representative as he/she will need to make a crucial decision about continuing with the pending transport and will indicate his/her decision using the ABN.

Optional Use

The ABN may also be used by your EMS agency, optionally, to alert the patient to possible personal financial responsibility outside of the mandated use.

The form may be used as a courtesy to inform the patient when there may be a personal liability for…

• Loaded mileage for a transport beyond the closest appropriate facility
• Ambulance transportation services provided to a patient who does not meet medical necessity criteria
• Ambulance transportation to a doctor’s office or other non-covered destination
• Convenience transports such as a transport to be closer to family or for personal physician treatment preference
• Use of higher level of service (ALS) when a lower level of service (BLS) would suffice
• Non-Transport Paramedic Intercept services
• Transportation by wheelchair, stretcher van or car services

Even though your EMS agency is permitted to bill any of the above without a signed ABN, your agency may choose to provide advance notice to your patients using this form so there is no “sticker shock” following the patient’s receiving your bill for services.