When addressing ABN issues, it is helpful to learn what patients are being told

It is never good when one of my team members tells a patient different information than what the insurance company does. When these questions arise, specifically regarding insurance coverage, it is helpful to know what patients are being told.

Here, we’ll discuss the Advance Beneficiary Notice (ABN) of Non-Coverage for Medicare Beneficiaries, a tool to communicate what is covered and what is not, and its requirements via CMS.

ACT AS A CONSUMER

Consider acting as a consumer to see what they see: Go to the insurance company’s web page and search for common answers. For example, regarding the ABN, here is what CMS says, available at bit.ly/2WuxA6l .

You may get a written notice called an “Advance Beneficiary Notice of Noncoverage” (ABN) from your doctor, other Health care provider, or supplier if you have Original Medicare and your doctor, provider, or supplier thinks Medicare probably (or certainly) won’t pay for the items or services you got.

However, an ABN isn’t required for items or services that Medicare never covers.

The ABN lists the items or services that Medicare isn’t expected to pay for, along with an estimate of the costs for the items and services and the reasons why Medicare may not pay.

A click through of this text on the site shows items or services Medicare “never covers,” and you will find listed: “Eye exams related to prescribing glasses.” For many patients, the evaluation of their eye health is a covered service yet, the piece that is never covered, if they have original Medicare, is the refraction. Do you have to have a patient sign an ABN for a refraction? According to the Medicare website, no — because it is a service that is never covered.

PROVIDE ANSWERS

An ABN is required, however, if the service is covered and you are concerned it will not be covered at this visit and you, as the doctor, feel the service is necessary to perform. In this case, you would then provide the ABN and discuss the three options the patient has, as described to our patients by Medicare:

You’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

• Option 1: You want the items or services that may not be paid for by Medicare. Your provider or supplier may ask you to pay for them now, but you also want them to submit a Claim to Medicare for the items or services. If Medicare denies payment, you’re responsible for paying, but, since a claim was submitted, you can appeal to Medicare. If Medicare does pay, the provider or supplier will refund any payments you made (minus the copayments and deductibles you paid).
• Option 2: You want the items or services that may not be paid for by Medicare, but you don’t want your provider or supplier to bill Medicare. You may be asked to pay for the items or services now, but because you ask your provider or supplier to not submit a claim to Medicare, you can’t file an appeal.
• Option 3: You don’t want the items or services that may not be paid for by Medicare, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.

An ABN isn’t an official denial of coverage by Medicare. You have the right to file an appeal if payment is denied when a claim is submitted.

If your team determines, prior to the visit, that you will need an ABN, make certain it is in the chart and ready to go. If testing is ordered, make certain the team is knowledgeable about ABNs and is able to fill in the blanks so you may keep the visit efficient.

In my experience, patients are appreciative of the explanation and, most of the time, willing to pay for a service the doctor finds necessary to provide the best care.

Additional resources regarding ABN on CMS’s website: go.cms.gov/2x38sJc and go.cms.gov/2vA0lmY . OM

DR. JASPER practices in West Palm Beach, Fla. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at april.jasper@pentavisionmedia.com.