shall we bill patients if Medicare denied the service

Billing Medicare Patients for Services Which May Be Denied

Medicare patients may be billed for services that are clearly not covered. For example, routine physicals or screening tests such as total cholesterol are not covered when there isno indication that the test is medically necessary. However, when a Medicare carrier is likely to deny payment because of medical necessity policy (either as stated in their written Medical Review Policy or upon examination of individual claims) the patient must be informed and consent to pay for the service before it is performed. Otherwise, the patient

has no obligation to pay for the test.

An Advance Beneficiary Notice (ABN), sometimes called a patient waiver form, is used to document that the patient is aware that Medicare may not pay for a test or procedure and has agreed to pay the provider in the event payment is denied. Each ABN must be specific to the service provided and the reason that Medicare may not pay for the service. Blanket waivers for all Medicare patients are not allowed.

Since both LMRPs as well as the new NCD for A1c include frequency limits, an ABN is appropriate any time the possibility exists that the frequency of testing may be in excess of stated policy. For example, if an A1c test may have been performed by another provider less than three months ago for a patient with uncomplicated diabetes, it would be prudent to obtain a signed ABN.

The CPT code modifier, -GA (Waiver of Liability Statement on File), is used to indicate that the provider has notified the Medicare patient that the test performed may not be reimbursed by Medicare and may be billed to the patient.

An ABN must: (1) be in writing; (2) be obtained prior to the beneficiary receiving theservice; (3) clearly identify the particular service; (4) state that the provider believes Medicare is likely to deny payment for the service; (5) give the reason(s) that the provider believes that Medicare is likely to deny payment for the specific service, and (6) include the beneficiary’s signature and date. Routine notices to beneficiaries which do nothing more than state that Medicare denial of payment is possible, or that the provider never knows whether Medicare will pay for a service, are not considered acceptable evidence of advance notice.

In the near future Medicare will issue a standard ABM form, in the mean time the following sample ABN meets the above requirements