An ABN form could cost you LOTS of money. —Do you know what it is?

Does this sound somewhat familiar?  You enter a doctor’s office for the first time; you look around awkwardly.  You are handed a clipboard with numerous forms on it (unless you were instructed to fill them out electronically from home).  There could be a big bad surprise in that pile of……………..forms.

Typically, people don’t LIKE going to the doctor’s office, no matter what kind of doctor and even if there is no particular worry. Might they find something you don’t expect?  It is a bit nerve-racking.  You want to get through all the forms as quickly as you can.  Often people (heaven help them) even want to ‘please’ the office staff or doctor with their answers.  Buried in this stack of papers could be a form called the ABN form.  If you are on Medicare it is definitely called that; for private insurance it may still be called an ABN (although ‘waiver’ is a term sometimes used with private companies).  An even more stressful scenario in which you receive this notice is at the point when a particular service is being strongly recommended for you by your physician – or worse, just prior to that service.  The forms for Medicare or private insurance may be slightly different but basically do the same thing.  So, what is the ABN?

ABN stands for Advance Beneficiary Notice.  How is that for a meaningless name?   Furthermore, those completing the billing can have entire manuals on this form and how to use it.  YOU on the other hand, may never have heard of it and figure it is just another ‘necessary’ paper.  You may wonder if it is a way for the physician to ‘CYA’ otherwise known as covering one’s own ……… assets (and there you would be very close to the truth).

The intent behind the ABN is that the physician means to be paid (understandably) one way or another.  If insurance doesn’t pay, you (as the patient) will.   No excuses like “I assumed it would be covered” or “but I didn’t understand what I was signing.”  You will be totally responsible.  Now this seems reasonable, right?  You should read what you sign and you should pay for services rendered.

But there are a couple seemingly unfair points stacked against the patient.

First people do not always fully understand what their insurance covers.   It is downright painful to read some of these policies and wade through the mud.  Be aware also that Medicare (and/or supplements) will never pay for any ‘non-covered service’ – period.   No negotiation.  Physicians really aren’t even supposed to try to bill for those services.  With private companies a physician may try to bill for a service they are aware will not be covered, especially if they are NOT participating with that particular insurance company.  There is nothing to stop them from trying either way, and simply coming back to the patient for payment based on the ABN.  [The EOB – or Explanation of Benefits code which is usually listed on a denial letter should indicate if the patient is allowed to be billed for the service.  With a bit of digging, you can often look this up online yourself.]

Second, while there is some gobblygook language (Okay, not the technical term) as to why ABNs are a safeguard for the patient, they are really just a safeguard for the doctor’s business.  Even if they don’t mention it, often the billing party KNOWS what generally is not being reimbursed ‘these days’ and what is denied payment.   You don’t!  Now, you may ask why the doctor needs protection.  Because often they have sincerely ordered a helpful service for a patient and yet the insurance company denies payment saying it was not needed.  [To clarify we are NOT talking about the service fee billed to the insurance company at $6,000 but for which the insurance only allows $155; that is a scenario the doctor faces regularly and often deals with by adjusting fees upward in anticipation.]  Instead, the point here is that the insurance company can technically list a service as covered, but still issue a denial of the need for that service to you.  Basically, second-guessing your doctor.

Third in the points unfair to a patient is about the assumption of what seems reasonable.  Perhaps you think these denied reimbursements only refer to odd and rare services?  NO.  You would be wrong if you thought that.  Many denials are for some pretty standard/basic care.  You could be asked to sign an ABN regarding anything for which the office fears non-payment.   This could include a pelvic exam from a primary care provider, an echocardiogram, an MRI, an ophthalmologist’s visual field exam, chiropractic care, lab and blood tests, physical therapy, or removal of a dermatological growth for prevention purposes – on and on.   How can this be?  Denials for such standard services?  Well if the physician sees it one way and the insurance company sees it as ‘not medically necessary’ guess who wins?  YOU don’t really matter in this decision.   [Of course, that is not my opinion of how it SHOULD be.]

Thus the use of the ABN form is not simply for care that is clearly excluded from your coverage.  Instead just as often it relates to services that are in your policy/plan but ones in which the physician and insurance company don’t see eye to eye – for YOUR circumstances.  It may not be described that way, but this is what it amounts to in reality.  Recently, ever-evolving ‘metrics’ have become the ‘gold standard’ used to track physicians’ performance — I won’t say who gets to keep the ‘gold.’   These metrics are what the insurance companies (and that includes the government Medicare program) are using to measure treatment and to evaluate (determine) payment.  They can be helpful for cost-cutting, which everyone is interested in.  Suspiciously however, sometimes they just seem like a handy rationale to increase denials.

The language of the ABN or any related from (while changing periodically) will generally have a modest introduction and then include check-off boxes such as below:

Example Intro: You are receiving this notice because your insurance company may not pay for all of the services that you receive during your visit to the office.  Read all of the literature.  Feel free to ask questions.

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Example of choices:

X  Yes  I want to receive these services.  [It then will have language that basically says that you the patient want Medicare or your insurance company billed but understand that you will be responsible for payment if the doctor is not reimbursed.  The form then ‘encourages’ you (my word) that this option will allow you the chance of appealing a decision.  Personally, I wouldn’t hold my breath on an appeal changing the decision.]

X  Yes.  I want these services, but do not bill Medicare (or insurance company name).  I agree to pay for services now as I am responsible for payment.  I cannot appeal if Medicare (or insurance) is not billed.  [Is this a straw-man option?  I am not sure, but fail to see the benefit – except to the physician’s office.  Perhaps this is available for a patient who wishes to submit their own paperwork to the insurance company.]

X  No.  I have decided not to receive these services.  I am not responsible for payment.  I cannot appeal.

X  Other.  Should I decide to accept these services in the future, or request them at a later date, I understand I will be charged and am totally responsible for payment in full.  [Instead of this option, that could commit you to something in the future which you have no current knowledge about, OR for which fees might change, how about writing in ‘NO ACCEPTABLE OPTION.’  Then add a  statement explaining that you are willing to revisit this form at a later – and more relevant – time.]

Ultimately, aside from hoping your desired service is covered, your choice is refusing service or agreeing to pay for it.  So consider the need for the service seriously as that little piece of ABN paper could cost you a lot of money.

Do not sign before thinking.  MOST IMPORTANTLY while it is not common, and admittedly not always appreciated by the doctor’s office, you have every right to ask for a written list of proposed services and costs BEFORE SIGNING.

One possible approach after the fact.  If your service is denied due to Medicare or the insurance company’s decision that is was not medically necessary, consider this.   WITHOUT being fraudulent or asking your doctor to commit fraud, do inquire whether there is another way for your physician to code the service based on your diagnosis.  This could solve the problem in some cases.

Otherwise all I can suggest is to become a medical activist!  Or check out one of the patient advocacy websites; examples include PAF (Patient Advocate Foundation), Patient Advocates, LLC  or the National Patient Advocate Foundation.

 

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