ABN (Advanced Beneficiary Notice)

In Medical Billing, we have our own language. Things such as EOBs, PPOs, HMOs, POSs, Catastrophic Cap, Deductibles and more can be very frightening if not understood. During training, medical coders and medical billers learn medical terminology. Medical Billing terminology is going to the next step to learn language medical billers face every day when interacting with patients, health benefits, and claims. There is a huge difference between otitis media and coordination of benefits (COB). Otitis Media is medical terminology. It is also a diagnosis that is converted by a coder from words to numbers that are recognized by an insurance company. COB is medical billing terminology, used by medical billers when interacting with multiple insurance policies carried by a patient. 

An ABN is a written notice from Medicare (standard government form CMS-R- 131), given to you before receiving certain items or services, notifying the patient:

• Medicare may deny payment for that specific procedure or treatment. 

• The patient will be personally responsible for full payment if Medicare denies payment.

An ABN gives the patient the opportunity to accept or refuse the items or services and protects the patient from unexpected financial liability in cases where Medicare denies payment. It also offers the patient the right to appeal Medicare's decision. You follow office policy on keeping the ABN form on file and you ad the modifier GA to the claim. Modifier GA informs Medicare of the ABN transaction. If you do not have the patient sign the ABN form and the claim is denied, then you cannot bill the patient for the denied claim.

The patient has the option to receive the items or services or to refuse them. In either case, the patient should choose one option on the form by checking the box provided, and then signing and dating it in the space provided.

When the patient signs an ABN and becomes liable for payment, the patient will have to pay for the item or service themselves, either out-of-pocket or by some other insurance coverage which they may have in addition to Medicare. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill is a matter between the patient and provider. If this is a concern for the patient, they might want to ask for a cost estimate before they sign the ABN.

Medical Billing Fraud & abuse

Fraud, waste and abuse prevention & training

If you identify potential fraud, waste, or abuse, please report it to us immediately so that we can investigate and respond appropriately. Please see the How to Contact Us section of this guide for contact information. Please note UnitedHealthcare expressly prohibits retaliation if a report is made in good faith.

• Fraud Is a false statement, made or submitted by an individual or entity, who knows that the statement is false, and knows that the false statement could result in some otherwise unauthorized benefit to the individual or entity. These false statements could be verbal or written.

• Waste Generally means over-use of services, or other practices that result in unnecessary costs. In most cases, waste is not considered caused by reckless actions but rather the misuse of resources.

• Abuse Generally refers to provider, contractor or member practices that are inconsistent with sound business, financial or medical practices; and that cause unnecessary costs to the health care system.

Effective January 1, 2009, the Centers for Medicare & Medicaid Services (“CMS”) modified certain rules and regulations of the Medicare Advantage and the Part D programs. The rules state that a compliance plan must include training, education, and effective lines of communication between the compliance officer and the organization’s employees, managers, directors, as well as first tier, downstream and related entities. This change clarified that plan sponsors, such as UnitedHealthcare, need to apply these training and communication requirements to all entities they are partnering with to provide services in Medicare Advantage or Part D programs.