Advance Beneficiary Notices (ABNs) intimidate a lot of suppliers, even the straight forward ones.

So how reliable is an ABN the patient won’t sign and return?

The good news is suppliers can still bill with the GA modifier and collect non-covered amounts from customers with a valid ABN – even an unsigned one – so long as they meet the requirements for delivering the notice.

Next Episode: Thursday, June 20, 2024

The Common Scenario

Unlike most other healthcare providers, DME reimbursement includes multiple medical necessity hurdles throughout a patient care period. The patient may meet coverage requirements at delivery but later fail a subsequent coverage requirement, and as a result, Medicare will not reimburse the supplier for future equipment rental periods or related orders. The supplier is also barred from pursuing the beneficiary directly for payment unless they have a valid ABN.

Delivering the Initial Notice to the Customer

The first step to securing a valid ABN is to notify the customer though a Medicare-approved method, including:

  • Postal mail,
  • Fax,
  • Secure email, or
  • Telephone.

When sending the ABN notification via postal mail, suppliers should send two copies: one for the customer to sign and return to the supplier and one for the customer’s records.

Best Practices for Verbal Notifications via Telephone

When calling a customer to notify them Medicare will no longer cover their equipment or supplies, it is important to explain why Medicare deems the items no longer covered in a way in which the customer can understand.

Suppliers should document the phone call in the customer notes, specifically noting the date, time, parties to the call (and their relationship to the beneficiary), the written reason for denial on the ABN, and any other pertinent information.

Immediately following the call, suppliers should follow up in writing by sending a properly drafted ABN by mail, fax, or secure email in accordance with the customer’s stated delivery preferences.

Notification Evidence

So long as the customer does not dispute the notification – which is not the same thing as agreeing with the actual coverage determination – the ABN is immediately enforceable for all future service dates … even without the patient signature. Of course, reliable notification evidence is critical.

With regards to verbal, over-the-phone notifications, call recordings can go far beyond well-kept phone logs. We recommend speaking with legal counsel first about proper procedure to avoid violating wiretapping laws or other applicable privacy regulations.

For all written notifications, we recommend suppliers pay for electronic tracking so they have objective evidence of the delivery.

If the customer does not return a signed ABN …

If the customer does not return a signed ABN after the notification and delivery steps outlined here, suppliers are required to make subsequent attempts to obtain a signed document. Medicare does not specify how many attempts, but it is certainly not infinite.

We recommend formalizing an internal policy to ensure that all patients are treated the same, and that policy should stipulate the frequency of follow-up attempts. We suggest a minimum of two follow-up attempts.

In the meantime, or should the customer never return a signed ABN, suppliers can use a copy of the unsigned ABN and evidence of notification attempts to support use of the GA modifier that signifies the supplier has an enforceable ABN.

Should a customer outright refuse to sign an ABN at the time of delivery notification, an unsigned document is still reliable. The staff member attempting to deliver the ABN notice should, however, document the refusal in the margin of the ABN document and add their own name and delivery date to the notation. The supplier should continue with follow-up attempts in accordance with their internal policy – notwithstanding the initial refusal – in accordance with their internal policy.

Discontinue Medical Necessity Modifiers

It is worth mentioning that suppliers should not include the KX or other medical necessity modifiers on claims after the ABN is enforceable and the GA modifier is added.

Ultimately, suppliers must engage the customer to validate delivery of the ABN, but they do not have to wait on a signature to bill claims with appropriate ABN modifiers.