IF YOU ARE SEEING PATIENTS WHO HAVE MEDICARE YOU NEED TO BE USING AN ABN FORM. THE BIG QUESTIONS ARE THE FOLLOWING:
Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?
My patient seemed confused about which of the options they should check. Can I just tell them which one they should check?
No! That could be construed as coercion. The official instructions state “Under no circumstances can the PROVIDER decide for the beneficiary which of the 3 checkboxes to select.”
Now, this doesn’t mean you can’t help them understand the three different options. You can answer their questions, but never tell them that they have to check a specific option.
Another problem that we have seen is that providers will check the option for the patient. The official instructions state that “Pre-selection of an option by the PROVIDER invalidates the notice.” You can NOT check that box for them UNLESS the patient is physically unable to check the box and they ASK you to do it for them. If that is the case, you must make a notation on the ABN about that unique situation. Although it is not required, it might be helpful to have someone witness that the patient asked you to do that for them.
Do we have to have patients with Medicare replacements that our office is not in network with sign an ABN with Option 2 marked?
Medicare Advantage (Part C), sometimes referred to as Medicare replacements, are not subject to the same rules as regular Medicare (Part B). Do NOT use the ABN for any Part C plans, regardless of whether or not you are in-network. Part C plans can have their own unique requirements regarding billing so it is necessary to find out that information from the payer.
Be careful about balance billing rules. They can vary by state and by plan so be sure that you do NOT charge more than is allowed. Coordinated care plans, such as HMOs and PPOs, and PACE plans are generally required to reimburse non-contracting providers at least the original Medicare rate for Medicare covered services. PFFS plans are permitted to establish their own fee-schedules and balance-billing rules, which, in some cases, differ from original Medicare payment rates and balance-billing rules. Although a non-network PFFS plan must reimburse all providers at least the original Medicare payment rate, a provider treating an enrollee of a PFFS plan will need to carefully examine the fee-schedule and balance billing rules of a PFFS plan to decide if the terms and conditions of participation warrant a decision to treat and be “deemed” a contracting provider. A decision to treat a specific PFFS plan enrollee is ad hoc and does not require the provider to treat other PFFS plan enrollees.
In situations when plans must pay the Medicare amount, plans must accept from providers the same billing forms used to bill original Medicare.
ATTEND THE LAS VEGAS DENTAL MEDICAL EXTRAVAGANZA TO LEARN ALL RULES ABOUT BILLING.