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Tip: Using software helps determine medical necessity

Compliance Monitor, March 31, 2004

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Advance Beneficiary Notices (ABNs) are an extremely intricate part of laboratory compliance, and using a software program can help, says Emma Wollschlager, a senior consultant with Sinaiko Healthcare Consulting in Los Angeles.

An electronic system can:

1. Eliminate the gray areas for front-end process. "When you have people in the admitting area, they are not coders and there's usually a lot of turnover. It's hard to train them sufficiently to make medical necessity determinations-even if they have a guide," she says.

"You want to have the least amount of judgment calls from front-end personnel."

2. Track the chain of events. Software programs specifically for the ABN process will track if the patient signed the ABN and save time in the long run. "When the billing department is submitting the bill to Medicare and they need to know what condition codes to put on it, if the patient signed the ABN or not, or if they can bill this to Medicare, etc., they don't want to be pulling paper ABNs from the front-end financial folders."

In addition, if physicians need to provide additional diagnostic information or supplemental orders, the information can be entered directly into the account through the software program.

"So when the back end is finally submitting the bill, they have all the information necessary to submit an accurate claim," Wollschlager says. "At the touch of a screen they know whether or not they can bill Medicare or determine what modifiers they need without having to go back to the paperwork, which I think logistically is the most difficult part of the whole process."

3. Educate physicians. "You can run reports by physician, because you have to enter in your ordering physician-so you can see which doctors are generally ordering things that are falling out of medical necessity guidelines," she says.

Then you can go back and educate the physicians by showing them what you were not paid for. You can show them that patients are getting billed our full fee schedule price for these tests and ask to be provided with more complete diagnostic information that is reflected in the patient's medical record, or you can ask the physician to examine their ordering practices.

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