ABNs: CMS, Medicare Advantage, & Commercial Payer Rules

The Medicare Advance Beneficiary (ABN) form is a written notice that you give to patients when you expect that Medicare will not pay for certain items or services. This webinar will explain the details and rules of Medicare ABNs. It can be confusing to know when you need to issue an ABN and whether it is mandatory or voluntary. If you submit the incorrect forms or make mistakes, you may face Medicare audits and penalties. In this live webinar, Expert David J. Vaughn, ESQ., will show you how and when to use the mandatory and voluntary ABN forms correctly and compliantly.

Many other payers also have similar forms and rules, so the compliance strategies you will learn in this session can apply to them as well. To protect you from unexpected charges and help you make informed decisions about your health care, Medicare requires providers, suppliers, and facilities to give you a written notice called an Advance Beneficiary Notice (ABN) before they provide items or services that Medicare may not cover. Medicare ABN is a liability waiver form that helps you avoid unpaid claims and protect your practice from serious financial and compliance risks.

• When an ABN must be used
• When an ABN may be used as a courtesy
• When an ABN should not be used
• How to apply ABN modifiers
• What rights does the patient have when filling out the ABN
• What if I don't receive an ABN?
• Know the patient/provider's financial rights and responsibilities
• Know how to properly use ABN Modifiers (GA, GX, GY, and GZ)
• What are Non-Medicare ABNs, and when to use them

• What is an ABN?
• What's New Since Last Year?
• Types of ABN
• When to Issue ABN?
• What Services Do ABNs Apply To?
  • Hospital, Hospice, Home Health Agencies
  • Physicians, SNFs, Home Health Agencies
  • Part A – Inpatient
  • Part B – Outpatient
• What Form Do You Use?
  • HINN – 1 – Entire hospital stay non-covered
  • HINN – 10 – Hospital requests Quality Improvement Organization to review discharge decision (can be used for MA)
  • HINN – 11 – Non-covered items during a covered stay
  • HINN – 12 – Non-covered continued stay
  • Physicians – CMS-R-131
  • SNFs – ABN for Part B; CMS-10055 is Part A
  • Hospitals
• Which CMS-R-131 Form to Use?
• How MUEs affect ABNs
• ABNs used in the Emergency Room
• Use of ABNs to Unbundle Charges
• How LCDs affect ABNs
• Filling Out the ABN
• Use of ABNs to shift liability to patients who have exceeded Medicare frequency limits
• Additional Considerations
• Patient options on the ABN form
  • Issues with Option 1 – Bill Medicare
  • The benefit of Option 2 – Don't Bill Medicare
• Qualified Medicare Beneficiaries (QMBs)
• Other Uses of ABNs
• Prior Experiences with Option 2
• Courtesy ABNs
• Required vs. Courtesy ABNs
• Multiple Entities Providing Care
• Routine ABNs
• Prohibited Use of ABNs
• ABNs for Extended Treatment
• Electronic vs. Paper ABNs
• What if the Patient Changes their Mind?
• What is the Patient Refuses to Sign?
• What happens if the ABN is filled out incorrectly?
• Collecting Patient Payments
• How Long the ABN Must be Kept?
• What are the refund rules if Medicare pays even though you have a signed ABN?
• Modifiers
  • GA – use when you have a mandatory ABN
  • GX – use when you issue a courtesy ABN for items Medicare never covers; combine with GY
  • GY – use for statutorily non-covered items; use with GX
  • GZ – use when you expect Medicare to deny, and you didn't get an ABN
  • GK – used when upgrading a piece of equipment
  • GL – same as GK, but you didn't get an ABN
• Things Medicare Never Pays
• Do Medicare Advantage programs use ABNs
• Can you use ABNs with Medicare prescription drug plans, and what ABN form must be used?
• Coercion
• Live Q&A Session

• Physician practices
• Medical providers who are involved in the payment process of their practice
• C-level executives
• Office staff and Billing Managers
• Medical Billing Companies
• Hospital Revenue Cycle Staff
• Physicians and Nurses
• Physician Assistants
• Nurse Practitioners
• Medical Assistants
• Practice Manager
• Office Managers
• Medical Biller, Coders and Auditors
• CDI Specialists
• Collection Staff
• Compliance Officers
• Patient Accounts Personnel
• Medical record supervisors
• Health Information Management Administrators and Technicians
• Other Personnel Interested in the Medicare Program and Payment System