As you well know, Advance Beneficiary Notices of Noncoverage (ABNs) are necessary whenever your organization determines that non-emergency Medicare services may not meet medical necessity. This allows the patient to determine if they want to receive the services and it alerts them to how much they may owe if the services are not found to be medically necessary. Ensuring ABNs are correctly issued requires the work of many departments.
First, staff must accurately determine the insurance coverage a patient has. If a patient does not have Medicare, or if they are on a Medicare Advantage plan, they do not have to receive an ABN. Some providers have created documents for patients with commercial insurance to let them know that their services may not be covered, but this is not required.
If your organization has accurately determined that a patient has Medicare, it is important to use the official form provided by the CMS and to legibly write the services being provided as well as the reason you believe they will be denied, alongside an estimate of what the services will cost. It is then pertinent to clearly explain the situation to the patient and to not select an option on the form for them. Physicians are allowed, and encouraged, to explain to the patient the positive and negative side effects of foregoing services. If the patient wants to move forward with the services but will not sign the ABN it is important to document this on the form itself. It can also be helpful to review your organization’s policy regarding deferral of non-emergent services.
Finally, communicating to physicians the importance of documenting everything necessary to prove medical necessity can mitigate these denials. There are many procedures where it is impossible to prevent Medicare from denying them for medical necessity, but there may be certain procedures at your organization that can be paid more often if the medical record is more completely filled out. Clearly describing why the prescribed diagnosis, presenting symptoms, and clinical documentation lead to a certain decision can help mitigate denials. Decreasing medical necessity denials in general is going to improve your A/R.
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