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Q: I get the impression that most hospitals aren't using Advance Beneficiary Notices (ABN) in the emergency department (ED) because there are so many problems. What do you consider to be the challenges?

Patient Financial Services Weekly Advisor, April 23, 2004

Although the topic of obtaining ABNs in the ED has been in the spotlight, very few facilities are actually attempting to obtain one. Most facilities are accepting whatever payments Medicare makes, and if there are services that are denied as not being medically necessary, most facilities are just writing them off.

There are many issues. The first is that emergency rooms have to be cognizant of the Emergency Medical Treatment and Labor Act (EMTALA), which makes sure patients are evaluated to determine their medical condition.

Second, it is hard to make determinations in emergency medicine as to what should and should not be performed, based on the patient's presenting condition.

Lastly, facilities are not permitted to obtain ABNs unless they are mostly certain that specific items will definitely not be covered by Medicare.

Each of these issues would be hard to determine for any physician, let alone any other hospital employee-especially since ABNs are supposed to be obtained before medical services are provided. If a hospital made the determination that a patient's condition might not be all that severe and requests a patient to sign an ABN, and the patient leaves and suffers some kind of injury or illness after leaving because the determination wasn't correct, the hospital could be in for some serious fines, and no one wants to risk that.

Facilities have the right to appeal denied services that occur in the emergency room, however. It can be argued that there's no way a physician could have known, based on the reasons patients present themselves, that certain tests wouldn't be covered by the final diagnosis. With proper documentation, Medicare has been known to overturn its original decision and pay all portions of a claim.

Overall, physicians and personnel who provide the medical screening examination should at least be given cursory education on both the ABN and EMTALA issues. It's never good practice to have physicians provide healthcare based on insurance qualifications. Having procedures in place to treat equally every patient who presents with similar reasons could help reduce the chances of providing services that insurance companies-including Medicare-might deny.

This question was answered by T. T. "Mitch" Mitchell, president of T. T. Mitchell Consulting in Liverpool, NY.

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