Use of “Routine” ABNs
By: Linda Payne
The purpose of an ABN is to inform a Medicare beneficiary that Medicare will probably not pay for an item or service, even if Medicare might pay for the service under different circumstances and allows the beneficiary to make an informed customer decision. The ABN applies to assigned as well as non-assigned claims.
The “routine” use of ABNs is not acceptable. By “routine” use, Medicare means giving ABNs to beneficiaries where there is no specific, identifiable reason to believe Medicare will not pay the claim. Physicians and suppliers should not give an ABN to a Medicare beneficiary unless the physician or supplier has some genuine doubt that Medicare will not make payment as evidenced by their stated reasons. Giving routine notices for all claims or services is not an acceptable practice although an ABN may be routinely given and considered only in the following circumstances:
• Services always denied for medical necessity based on a national coverage decision.
For example: IVIG for a diagnosis of Myasthenia Gravis
• If a provider is supplying an item that Medicare does not have a specific policy for, an ABN would be appropriate because Medicare will have to consider.
Examples of using an ABN incorrectly include:
• “I never know if Medicare is going to pay”
• “I don’t know if Jane’s Home Health might have already been paid for this”
Even though Medicare has begun to enforce all requirements surrounding ABNs, if a supplier submits a non-assigned claim the supplier is not required to accept the Medicare allowed amount as payment in full.
If you have obtained an ABN according to the guidelines as stated by Medicare, you are to use the GA modifier when submitting your claim.