Navigating health care has its challenges. For starters, finding the right providers to get the treatment you need can be difficult. Dealing with insurance companies adds another layer of complexity and frustration, and so does finding accurate and accessible information about all of the intricacies of Medicare.
An Advance Beneficiary Notice, also known as a waiver of liability or Medicare waiver, is issued by medical providers to Medicare recipients, warning that services might not be covered. The ABN formally and legally transfers liability for payment of services to the Medicare recipient instead of Medicare. Your doctor may ask you to sign an ABN stating that if you receive treatment from them, it may not be covered by Medicare. Your signature doesn't automatically mean you'll have to pay for the service, as Medicare may still need to review the claim.
What Type of Medicare Is Subject to ABNs?
You'll only receive an ABN if you have Original Medicare, which consists of Part A (hospital insurance) and Part B (doctor’s visits, medical equipment, ambulance service). If you have a Medicare Advantage plan from a private health insurance company, you won't receive an ABN for any service or treatment. The Medicare Advantage plan will determine whether or not the service is covered.
What Information Is on an ABN?
Medicare controls the exact information on those ABNs. If Medicare's rules aren't followed, you may not be responsible for payment. Every ABN requires specific information, including:
- Your full name
- The name, address, and phone number of the provider issuing the ABN
- The name of the service or item that might not be covered
- The reason Medicare may not pay
- Estimated cost
In addition to this information, other rules govern ABNs, too. The form, for instance, has to be a single page or less, with attachments allowed for specific services. The information on the form must be legible, and your provider is required to make sure that you can read it and understand it. They're also required to answer all of your questions about it.
Providers can't issue an ABN to anyone who’s under duress or in emergency medical situations. If you have a stroke, for example, you can't be presented with an ABN while being rushed to the hospital or while you're in the emergency room.
Often called an Advance Beneficiary Notice of Noncoverage, an ABN can't be presented by a provider immediately before an appointment or procedure. You're required to have time to consider all of your options.
If the ABN you're given doesn't follow these specific rules to the letter, you may not be liable for payment even if Medicare denies your claim.
What Do I Do if I Get an ABN?
When you receive an ABN, you'll be given three options. You'll have to check the box next to the appropriate option, then sign and date the notice. Your options are:
- You want the items or services that possibly won't be covered by Medicare. The provider may ask you to pay for the service upfront, but this option also indicates that you want the provider to attempt to bill Medicare. If Medicare denies the claim, you have the option to appeal. If Medicare pays, the provider will refund the amount, minus your deductible or copay.
- You want the items or services, but you don't want the provider to attempt to bill Medicare. Like the first option, the provided may require an upfront payment. But a claim won't be filed so there's no option for you to appeal.
- You don't want the items or services, and you're not responsible for payment. If you choose this option, a claim won’t be submitted to Medicare, and you won’t be able to file an appeal.
How Does the ABN Appeal Process Work?
If you choose Option 1 and Medicare denies the claim and you believe the item or service should be covered, you have the option to appeal the decision. To file an appeal, you must:
- Look at your Medicare Summary Notice (MSN). Your appeal must be filed by the date listed on your MSN, or you must make a compelling case for why you've missed the deadline.
- Fill out a Redetermination Request Form and send it to the company that handles your Medicare claims. You'll find their address on your MSN.
- You can also write to the claims address, instead of filling out the form. To do this, you'll need to include the following information in your written request:
- Your name, address, and Medicare number
- The specific items or services you disagree with, and their dates
- An explanation of why you think the items or services should be covered
- The name of your representative if you've appointed one
- Any other information that you think might help your case
You'll generally receive a decision within 60 days. If your items or services are going to be covered, the information will be listed on your next MSN.
