Advance Beneficiary Notices - How and When to Use Them

What You Need to Know

ABNs provide formal notice to beneficiaries that Medicare may not cover a specific service, procedure, or item. The primary purpose of an ABN is to inform patients about potential out-of-pocket expenses, allowing them to make informed decisions regarding their care.

You should provide an ABN before delivering services or items you expect Medicare to deny. Typical denial scenarios include:

• Non-covered services: When a service or item is known to be generally not covered by Medicare.
• Medically unnecessary services: When the provider believes that the service or item, though generally covered, will not be considered medically necessary for the specific patient in question.
• Frequency limitations: When a patient requests a service or item more frequently than Medicare's coverage policy allows.

When filling out an ABN, the form should include a detailed description of the service or item, the reason Medicare may deny coverage, and a clear estimate of the costs for which the patient will be responsible. You should explain the options available to the patient, including refusing the service or item, and the potential health implications of such decisions.

The patient (or their representative) must be given time to ask questions and consider their options before signing the ABN. Once signed, the provider keeps the original copy, and the patient receives a duplicate.

What this Means for You

It is important to understand the situations in which you can appropriately use an ABN. We are aware that some health care providers systematically use ABN's when they are unsure whether a claim will get paid. For example, they serially use the form when they

• are unsure whether the patient has previously received a same or similar device;
• think that their medical documentation may be insufficient; or
• think that a physician's corroborating documentation may be insufficient.

It is not appropriate to use an ABN in any of these scenarios.

You should limit ABN use to those situations where Medicare policy declares services non-covered, medically unnecessary, or where you are providing items in excess of established frequency limitations. Inappropriately billing Medicare beneficiaries for services via an ABN can expose you to investigations, claim recoupments, and additional monetary penalties.

If you are unsure how to fill out the ABN, CGS has a helpful ABN tutorial web page that we recommend you use to make sure you are filling it out correctly.