An Advance Beneficiary
Notice (ABN) allows a beneficiary to make an informed consumer decision by
knowing in advance that the beneficiary may have to pay out-of-pocket. An ABN
is not needed where the item or service is categorically excluded from Medicare
coverage or outside the scope of the benefit.
An ABN is used when the physician/practitioner believes that Medicare will not
make payment, while private contracts are used for services that are covered by
Medicare and for which payment might be made if a claim were to be submitted.
Private Contracting Rules When Medicare is the Secondary Payer
The opt-out physician/practitioner must have a private contract with a Medicare
beneficiary for all Medicare-covered services notwithstanding that Medicare
would be the secondary payer in a given situation. No Medicare primary or
secondary payments will be made for items and services furnished by a
physician/practitioner under the private contract.
