Billing Medicare Patients for Services Which May Be Denied
Medicare patients may be billed for services that are clearly not covered. For example,
routine physicals or screening tests such as total cholesterol are not covered when there is
no indication that the test is medically necessary. However, when a Medicare carrier is
likely to deny payment because of medical necessity policy (either as stated in their written
Medical Review Policy or upon examination of individual claims) the patient must be
informed and consent to pay for the service before it is performed. Otherwise, the patient
has no obligation to pay for the test.
An Advance Beneficiary Notice (ABN), sometimes called a patient waiver form, is used to
document that the patient is aware that Medicare may not pay for a test or procedure and
has agreed to pay the provider in the event payment is denied. Each ABN must be specific
to the service provided and the reason that Medicare may not pay for the service. Blanket
waivers for all Medicare patients are not allowed.
Since both LMRPs as well as the new NCD for A1c include frequency limits, an ABN is
appropriate any time the possibility exists that the frequency of testing may be in excess of
stated policy. For example, if an A1c test may have been performed by another provider
less than three months ago for a patient with uncomplicated diabetes, it would be prudent
to obtain a signed ABN.
The CPT code modifier, -GA (Waiver of Liability Statement on File), is used to indicate that
the provider has notified the Medicare patient that the test performed may not be
reimbursed by Medicare and may be billed to the patient.
An ABN must: (1) be in writing; (2) be obtained prior to the beneficiary receiving the
service; (3) clearly identify the particular service; (4) state that the provider believes
Medicare is likely to deny payment for the service; (5) give the reason(s) that the provider
believes that Medicare is likely to deny payment for the specific service, and (6) include
the beneficiary’s signature and date. Routine notices to beneficiaries which do nothing
more than state that Medicare denial of payment is possible, or that the provider never
knows whether Medicare will pay for a service, are not considered acceptable evidence of
advance notice.
In the near future Medicare will issue a standard ABM form, in the mean time the following
sample ABN meets the above requirements.
