Medicare Advantage Plans May Not Use ABN Forms

CMS recently notified Medicare Advantage (MA) plans of improper uses of the Advance Beneficiary Notice (ABN) in a letter dated May 5, 2014.

This notice appears to require contracted providers on MA panels to get a “pre-authorization” before providing noncovered services to beneficiaries – although not referred to by those words.  Additionally, providers don’t appear to have the option of just giving an advance notice to patients; they must go through an authorization process. 

The CMS letter to the MA plans can be viewed here (via the United Healthcare site).  The notices and letters are the same on other MA plans that we can view publicly.

Of note:

  • CMS directed MA plans to immediately cease use of any plan-specific “customized” documents.
  • One MA plan insurer, United Healthcare, had a customized “ANN” (Advance Notice of Noncoverage) in place of the official CMS ABN form.   United Healthcare’s MA plan webpage now shows the ANN as discontinued.  Other MA plans had similar documents for use.
  • The CMS letter notes the following important points:
    • “ … [we] have received reports of Medicare Advantage Organizations (MAO) … issuing notices to enrollees that advise of non-coverage for an item or service … the [advance] notices appear to be based on … the ABN … used in original Medicare …”
    • “MAOs should  immediately cease this practice …”
    • “… the ABN … [does] not apply in the Medicare Advantage context … because a Medicare Advantage enrollee has always had the right … to an advance determination of whether services are covered prior to receiving such services.”
    • “The enrollees request … from a contracted provider … is a request for an organization determination …”
    • “ … [MAOs] are prohibited from circumventing the organization determination process.”

We advise that you check with the MA plans with which your practice participates immediately to see how they want to you handle the critical aspect of notifying their beneficiaries of noncovered items or services so you do not provide potentially non-reimbursed services without (the patient?) being made aware. 

As always, if you need assistance with this or other issues, Corcoran Consulting Group can help.  We have multiple training and chart review options to accommodate your particular needs.  Call us to learn more.   (800) 399-6565

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