With a new Advanced Beneficiary Notice form introduced, now is the time to review how to use them properly.

Despite being related to payment and reimbursement, an Advance Beneficiary Notice of Noncoverage (ABN) generally originates in the eyecare practice’s clinic — not its billing department. Since the Centers for Medicare & Medicaid Services (CMS) is requiring providers to use a new ABN form — CMS-R-131 — as of June 30, 2023,¹ now is a great time to review how the ABN is initiated in the clinic.

ABNs explained

ABNs are used to obtain consent and direction from patients for services that may not be covered by Medicare in a particular instance. They are issued by providers only to Medicare Part B beneficiaries in situations where payment is expected to be denied.

When completed correctly, the ABN outlines these patients’ options regarding the service in question by having them choose:

• To have the service and bill Medicare, while agreeing to pay if the claim is refused;
• To have the service and not bill Medicare, instead choosing to pay out of pocket; or
• To decline the service entirely.

For example, screening tests are not covered by Medicare Part B. Often used as a screening test, fundus photos are covered when they are deemed medically necessary, and the practice meets the order and interpretation and report requirements. If screening fundus photos are offered, an ABN would be used to inform patients the screening photos are noncovered and let them choose whether to have the fundus photos (agreeing to pay out of pocket if necessary).

Appropriate use of ABNs

When indicated, ABNs must be executed before services are performed, which usually translates to the clinical, surgery scheduling, technician, or front desk staff presenting the form to patients. Regardless of who presents the form, all staff should be able to explain its reasoning and answer patient questions.

Medicare’s instructions for the ABN form dictate that it must be fully completed, without blanks, before presentation to the patient for their choice and signature. Fields include the patient’s name at the top, exact service being considered, the reason Medicare may not pay, the associated fees, the checkbox for the patient’s choice regarding the service, patient signature, and date. The form is then kept on file, a copy is given to the patient, and an appropriate modifier is billed, along with the service’s current procedural terminology code, to indicate the executed ABN is on file.²

The ABN may now also be used to provide notification of financial liability for voluntary items or services that Medicare never covers. When the ABN is used in this way, it is not mandatory and also it is not necessary for the beneficiary to choose an option box or sign the notice.² (An example of a noncovered service is a refraction, which is often described in the practice’s financial policy to which the patient agrees at their first visit, eliminating the need for per-service acknowledgement.)

Preparing for change

With changes on the horizon, now is an excellent time for practices to revisit their ABN process. Refreshing staff and provider training and updating ABN form copies throughout the practice can help prepare for the new form’s mandatory use date of July 1, 2023. OP

REFERENCES

1. Centers for Medicare and Medicaid Services. FFS ABN. https://www.cms.gov/medicare/medicare-general-information/bni/abn . Accessed May 5, 2023.
2. Centers for Medicare and Medicaid Services. Form Instructions Advance Beneficiary Notice of Non-coverage (ABN) OMB Approval Number: 0938-0566. https://www.cms.gov/medicare/medicare-general-information/bni/downloads/abn-form-instructions.pdf . Accessed April 28, 2023.

Ms. Brown is a senior consultant with BSM Consulting in Tucson, AZ. She has experience in the ophthalmic industry holding managerial, clinical, and surgical roles for more than 30 years.