When does Medicare require that a patient sign a waiver of liability?
The patient (or, in some cases, a patient's authorized representative) must sign a waiver of liability (ie, advance beneficiary notice, or ABN) when a physician or health care provider has good reason to believe that Medicare certainly or probably will not pay for certain services because they fail to meet the program's requirements relating to "reasonable and necessary" care. The most common scenario occurs when a diagnosis code is not listed under a local coverage determination as an appropriate reason for a procedure, and the carrier denies the service as "not medically necessary." Waivers also are required for procedures or services performed more frequently than listed in the Medicare exclusions from coverage guidelines. Two procedures that fall into this category are screening mammograms and colorectal cancer screens performed more frequently than Congress allows.
Prior to performing the service, you must notify the patient in writing that Medicare likely will deny payment. The ABN must indicate the reason for probable denial. To be acceptable, an ABN cannot state simply "medically unnecessary" or its equivalent as the expected reason for denial. The ABN is intended to give a Medicare beneficiary a reasonable idea of why a Medicare denial is expected so the beneficiary can make an informed decision about whether to receive the service and pay for it personally. If the patient is not notified prior to the procedure and does not sign the waiver, the patient cannot be held financially responsible for the service performed. For more details, see the May 2008 Radiology Coding Source, "Advance Beneficiary Notice of Noncoverage (ABN) Handling."
May I use a blanket waiver form for all Medicare patients?
No, Medicare will not accept a blanket waiver form. The ABN should be obtained when there is a specific reason to believe the service will be denied and the specific reason must be listed. You may develop a standardized waiver form, but it is required to be specific to the patient and the procedure. For Office of Management and Budget (OMB) approved ABN form, please visit www.cms.hhs.gov/BNI.
Does Medicare require specific wording in ABN waivers?
Yes, specific wording is required to be listed in the ABN waiver. You should write the ABN on your practice's letterhead, including the name and address of your practice. Make sure to differentiate "not reasonable and medically necessary" denials (based on diagnosis) from "noncovered" (ie, services excluded by law or under a nonbenefit category) denials. Noncovered services do not require a waiver, and the patient is responsible for payment. To access the ABN guidelines, visit the http://www.cms.hhs.gov/manuals/downloads/clm104c30.pdf.
Do I need to use a specific modifier on the claim form if I use an ABN?
If you use an ABN, you should add a GA modifier to the claim. This indicates to Medicare that you notified the patient prior to performing the procedure and that the signed waiver is on file. Other modifiers that are used to indicate that the patient has acknowledged responsibility or refused to sign are GY and GZ respectively. To see how the modifiers are used, visit the http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
Do I need to attach a copy of the signed ABN with each claim form?
No, you do not have to send an ABN with all claim forms, unless your carrier requested it. You should keep the signed waiver on file in case your carrier requests a copy.