Revenue Cycle

SNEAK PEEK: Be prepared for ABN changes

Patient Access Weekly Advisor, November 12, 2008

More than a year after several rounds of review on proposed revisions to existing Advance Beneficiary Notice (ABN) Forms ABN-G and ABN-L, CMS published revised Form CMS-R-131.

As with the prior ABNs, the revised ABN is designed for use by hospitals, physicians, and certain other furnishers of healthcare services (“healthcare providers”) to notify Medicare beneficiaries when outpatient services are expected to be denied, primarily in the following circumstances:

  • The services fail to meet Medicare’s medical necessity guidelines
  • The services are screening services that are provided more frequently than Medicare provides a benefit for
  • The services are custodial in nature

In order to be effective, such notice must occur prior to the performance of these services. This protects beneficiaries from unexpected financial liability. The provisions in Medicare law that require such protections are referred to as the “limitation on liability” provisions. Noncoverage most commonly arises with respect to diagnostic services (lab tests, imaging services, etc.). In such cases, the diagnostic information on the physician order does not support the medical necessity of the services ordered.

For the full story, see the article on the Patient Access Resource Center coming in December.


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