Lately there has been a great deal of confusion on the proper use of Advance Beneficiary Notices (ABNs) for Medicare beneficiaries. An ABN is a Medicare form that is used to advise a patient, before providing services, that the transport may not be covered by Medicare and that the patient may have to pay for the services themselves.
Unfortunately, most things written by Medicare about the use of ABNs by ambulance providers are raising more questions and causing more confusion than providing clear answers. So, the point of this EMS Law Tip is to try to help you keep the ABN issue in perspective with something we call “The Head Scratch Test.” Here’s the first bit of perspective:
ABNs are rarely needed in the ambulance business!
Due to some fairly complicated legal rules that we don’t really need to explain in detail, ABNs are needed only for a very small subset of ambulance transports. Thanks to the efforts of the American Ambulance Association, we now have a relatively straightforward list of those instances where an ABN is needed, such as a “level of care downgrade” (such as a downgrade of a claim from ALS 2 to ALS 1 or ALS to BLS) or an air ambulance-to-ground ambulance downgrade. In this Tip, we’re going to focus on one example you might be the most likely to encounter: a transport of a Medicare beneficiary from a residence or a nursing home to a hospital for something that should instead be done at the point of origin. Now, many ambulance providers have thrown up their hands exclaiming “how are we supposed to know if something should be done at the nursing home instead of a hospital? Fair question.
We answer this question by suggesting that ambulance services use “The Head Scratch Test!” What is The Head Scratch Test? It’s simply this: if you’re loading a Medicare patient into the back of an ambulance at a nursing home and scratching your head wondering why you need to be taking the patient to the hospital for this, think ABN.
For example, if the patient is being taken to the hospital for something as simple as a routine blood draw, suture removal, or the replacement of a simple indwelling catheter, those would be examples of things that probably could and should be done at the nursing home. In cases like that, it is more economical for Medicare to pay for the services being done at the nursing facility than paying for an ambulance transport to a hospital. If you file such a claim, Medicare will deny it as “not reasonable and necessary.” In such a case, you can’t bill the beneficiary following a Medicare denial unless you obtained a signed ABN prior to doing the transport. In other words, if your service either knew or should have known that the service could be more economically performed at the point of origin than at the destination, the ABN rule would apply. The reality is that your crews may not have any idea why the patient is being transported, except some general information from the facility staff, which is why it is important for dispatch to obtain this information in advance wherever possible during the call intake process.
The ABN rules say that you shouldn’t routinely use ABNs on every trip, so be sure your crews know to use the form only in the limited circumstances set forth by Medicare, including the one we are discussing in this Tip. For other examples, take a look at the Medicare ABN form we customized for ambulance services — CLICK HERE for this downloadable ABN form.
Remember, you must use this standard Medicare ABN form in those few instances where ambulance transports require ABNs. And, fortunately, ABNs are never to be used in emergencies or instances where the beneficiary is under duress (which of course, should be documented on your patient care report). In addition, ABNs are not required to be able to bill a beneficiary following an ordinary medical necessity denial (because these are denials under the “other means of transport contraindicated” part of the Medicare law – Section 1861(s)(7), not the “reasonable and necessary” part of the law – Section 1862(a)(1), which triggers the ABN requirement) or for transports where you can’t obtain a Physician Certification Statement (PCS) or trips to doctor’s offices or other locations that don’t meet Medicare’s destination requirements.
The most effective way to use an ABN is to do a thorough job of screening transport requests in your call intake process. We will discuss this and other important issues in this area in our live EMS Law Audio Conference on September 18, 2003, “Organizing Your Billing Operation From A to Z: Dealing With Claims, Credit and Collections,” featuring national collections expert Maggie Adams and the attorneys from PWW. Click here for more information on this and other audio conferences
(c) Copyright, 2003, Page, Wolfberg & Wirth, LLC.
