Medicare Patients: Advanced Beneficiary Notice
Will Medicare pay for my tests?
Certain lab tests are not covered by Medicare. When this is the case, you will receive a form called an Advance Beneficiary Notice. This notice states that your doctor believes your lab test will not be covered by Medicare. It explains the reasons your doctor believes your lab test will not be covered, and states that you will be expected to provide full payment if Medicare denies payment.
It is important to understand what your options are when you are given an Advance Beneficiary Notice. The following information is from the official government site for people with Medicare.
What is an Advance Beneficiary Notice (ABN)?
An ABN is a written notice (the standard government form CMS-R-131), that you may receive from physicians, providers, or suppliers, before they furnish a service or item to you, notifying you:
- That Medicare will probably deny payment for that specific service or item in your case.
- The reason the physician, provider, or supplier expects Medicare to deny payment.
- That you will be personally and fully responsible for payment if Medicare denies payment.
An ABN also gives you the opportunity to refuse to receive the service or item.
When I am liable for payment because I signed an Advance Beneficiary Notice (ABN), how much can I be charged?
When you sign an ABN and become liable for payment, there are no Medicare charge limits which apply to the supplier’s, physician’s, or provider’s charges. Medicare fee schedule amounts and balance billing limits do not apply. The amount of the bill in such cases, therefore, is a matter between you and the supplier, physician, or provider. Again, before signing an ABN, be sure to ask how much it will cost you.
What if I refuse to sign an Advance Beneficiary Notice (ABN) but I want the service or item anyway?
If you want the service or item, you should choose “Option 1. YES” and sign and date the ABN. If you refuse to sign, your supplier, physician, or provider, that takes assignment of your Medicare claim, may decide not to provide the service or item to you or may have a second person witness your refusal to sign the agreement and then furnish you the service or item. If an ABN being given to you is witnessed, you may be held liable because you are on notice of the likelihood of a Medicare denial. That is what makes you liable under the law.
There are some exceptions, however. You cannot be held liable if you do not sign an ABN when items and services are furnished to you and assignment is not accepted by your supplier or physician. You also cannot be held liable if you do not sign an ABN when certain medical equipment and supplies are furnished even on an assignment basis. This exception applies with respect to unsolicited telephone contacts, failure to obtain advance determinations of coverage, and suppliers which do not have Medicare supplier numbers. But, remember, in these cases, your physician or supplier probably will not provide the service or item to you if you refuse to sign the ABN and agree to be responsible for payment.
If I receive an Advance Beneficiary Notice (ABN), what are my options?
Whether you decide to receive the service or item or to not receive it, you should choose one option by checking the box provided, and then sign and date the ABN.
You may choose “Option 1. YES” and receive the service or item. If you choose Option 1, your claim will be sent to Medicare. You may be billed while Medicare is making its decision. If Medicare does pay, you will be refunded any payments you made that are due to you. If Medicare denies payment, you will be personally and fully responsible for payment. You will have the right to appeal Medicare’s decision. Medicare will not decide whether to pay unless you receive the service or item and have a claim submitted.
You may choose “Option 2. NO” and not receive the service or item. If you choose Option 2, your claim will not be sent to Medicare. You will not be able to appeal the supplier’s, physician’s, or provider’s opinion that Medicare won’t pay.
What information must be included in an Advance Beneficiary Notice (ABN) for a Part B service or item?
The ABN must identify the service or item for which denial is expected, and it must clearly state the reason a Medicare denial is expected. It may include an estimate of the cost for the service or item. Be sure to ask how much it will cost you. You may choose to receive the service or item and to be responsible for payment if Medicare does not pay (in that case, you should choose “Option 1. YES”), or you may choose not to receive the service or item (in that case, you should choose “Option 2. NO”). Be sure to keep a copy of your signed ABN for your records.
Available resources for assistance & questions
Empire Medical Services: http://www.empiremedicare.com/index.html
Phone: (800) 633-4227
TTY: (877) 486-2048
University of Rochester Medical Center Department of Pathology and Lab Medicine Billing office:
Phone: (585) 784-8865