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The ABCs of ABNs: What outpatient rehab providers should know

Rehab Regs, April 1, 2003

The ABCs of ABNs: What outpatient rehab providers should know

Mildred Smith, the patient you have treated at your outpatient rehab facility or clinic, reached her goals, and you-the PT-feels there's no longer a reasonable expectation of improvement. But Mildred, a strong-willed woman who receives benefits under Medicare, remains adamant. She insists that you continue with therapy.

What do you need to do in this situation? You must issue an advance beneficiary notice (ABN), which is the form known as CMS-R-131-G, and present it to Mildred for her signature. The ABN states the services in question and the reason why you feel Medicare will not provide reimbursement. Should your carrier or fiscal intermediary (FI) agree with this assessment, Mildred's signature on the ABN attests to the fact that she agreed to pay for it privately.

It sounds simple, but many outpatient rehab providers may feel less than sure about the rules and regulations surrounding ABNs. This is likely due to the fact that the subject of ABNs comes up once in a blue moon for most practitioners, says Peter R. Kovacek, MSA, PT, president of Kovacek Management Services, Inc., in Harper Woods, MI.

"There's a specific form and specific guidelines when it comes to issuing ABNs," Kovacek says. "Some clinicians may want to be able to put [instructions for completion] of ABNs on a three-by-five card, but you really have to do your homework. I think it's so rarely used that everyone forgets."

While the savvy practitioner keeps CMS' guidelines on ABNs at their fingertips (see related story below), the following points serve as an ABN primer, industry experts say:

1. Know when you need to issue an ABN. Although there are a number of reasons for which you may need to issue an ABN, in most cases it comes down to a question of whether the therapy service delivered is medically necessary and requires the skills of a therapist. Therapists confronted with this situation will find themselves asking a host of questions, says Rick Gawenda, PT, director of rehab services for Detroit Receiving Hospital.

"You need to decide whether the therapy [prescribed] is still skilled and medically necessary and whether the patient is expected to improve in function," says Gawenda.

"Therapists may need to [rely] on their experience. Sometimes a therapist may realize a patient has reached a plateau sooner than expected and will know that an ABN is necessary at that time, rather than deliver those few extra treatments and perhaps see the therapy claim get denied. When patients achieve their goals or reach a plateau, it's time to discharge them and let them continue independently with a home exercise program."

2. Get the patient's signature. Gawenda recommends that you fill out the ABN in front of the patient, which is the procedure used within his organization, and describe in laymen's terms the services in question and reasons why they may not be covered.
"It has to state the date, what the therapy is, and why you feel the services will not be covered," Gawenda says. "It's pretty detailed, and the patient needs to sign it."

Although CMS does not require you to provide an estimated cost, they recommend that you give one to patients so they have an idea of cost should they decide to continue.

In some instances, this may be a moot point. Once the therapist fills out the ABN and explains the terms to the patient, he or she may decide to end therapy rather than incur the cost privately. You can't give the patient a blank ABN to sign.

"I have not had one patient sign it yet," Gawenda says. "Basically when you submit the records to [the FI or carrier for Medicare reimbursement], the ABN goes with it. Many times-once the carrier or FI receives this-chances are good they're going to deny payment. Even if they don't do that, a lot of patients don't want to take the risk of financial liability and will say that they don't want the therapy."

3. Keep the patient informed. Communicate with patients regarding their progress-it may head off the need to go through the ABN process, Gawenda says.

"In conjunction with the patient, the therapists should be discussing the treatment and how they're progressing through therapy. The therapist should say, 'Okay, Mrs. Smith, you've done well, I no longer see a need for the service.' It's those instances in which Mrs. Smith doesn't agree and wants to continue, but the therapist thinks there's no reason for skilled therapy, that we discuss the ABNs."

4. Cross the T's and dot the I's. Let's say the patient doesn't agree with the PT's assessment at the X-cellent Rehab Clinic, insists upon further therapy, and signs the ABN. Now what? The clinic must submit documentation, including the ABN, to the carrier or FI for their review, which will determine whether services were appropriate or medically necessary, Gawenda says.

"They may look at the documentation and say, 'Yes, it was skilled and medically necessary, and we'll pay for it,' or 'Yes, we agree with you, and we're going to deny payment for these treatment dates,' " Gawenda says. "They base their decision upon the documentation."

5. Emphasize to the patient he or she is likely going to pay out of pocket. The therapist suspects that Medicare won't pay for it and explains this to the patient, who wonders whether secondary insurance may pick up the tab. The therapist should explain to the patient this is not likely to occur.

"When the patient is liable, you have to collect from [him or her]," Gawenda says. "Usually, if Medicare is the primary insurer and rejects the claim, the secondary payer will deny for the same reason."
6. Ask questions if you issue ABNs frequently. Part of the confusion surrounding ABNs occurs because they are issued only in rare situations-watch out if you find yourself issuing them on a regular basis, Kovacek says. "They should only be used in specific instances and, quite frankly, it should be rare," says Kovacek. "If it's more common, I'd take a look at [your practices]."

7. Remember the FI or carrier makes the determination-and sometimes you may be pleasantly surprised. If you anticipate that your FI or carrier may deny the services for which you submit an ABN, remember that they have the final say. Sometimes, you may be pleasantly surprised, says Kovacek. He recounts a situation in which he submitted an ABN for a patient in the summer of 2002. The patient continues to visit the clinic for therapy services-and Medicare continues to reimburse for the service delivered to this patient three times a week.



More info on advance beneficiary notices

Outpatient rehab providers must remember certain items about advance beneficiary notices (ABN)-most notably, Medicare regulations stipulate that therapists can't issue blanket notices. Rather, the notices must contain specific reasons the therapist feels Medicare will not cover services delivered, says Peter Kovacek, MSA, PT, president of Kovaceck Management Services, Inc., in Harper Woods, MI.

Rather than rely on others' interpretations of ABN policies, savvy therapists must educate themselves with the available CMS resources. Reference the following two sources when confronted with questions about ABNs:

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