Navigate Advanced Beneficiary Notice for Noncoverage - Witness Positive ROI in 2021

Claims processing for Medicare reimbursement involves a complex set of procedures. Keeping up with the constantly changing rules and guidelines can also be extremely challenging. With reimbursement methodologies being incredibly complicated, many providers struggle with accurate submissions and end up making costly mistakes. Advance Beneficiary Notice (ABN) is a waiver notice that is an integral part of these claims procedures.

Optometry practitioners are required to give patients an ABN prior to providing services that may not be covered under Medicare. This can be extremely helpful to the providers in transferring potential financial liability to the Medicare beneficiary. ABN can thus improve positive returns for optometry providers by protecting them from significant financial losses.

Understand and incorporate the following ABN practices to reap maximum benefits from your optometry billing efforts.

There are instances when specific healthcare services or items are not covered by Medicare. This might happen for services such as routine eye care exams or eyeglasses that are not considered medically necessary by Medicare. Not following the defined guidelines on how and when to submit the claims can also lead to rejections or denials. In such cases, providers must give notice to beneficiaries that the services they require are not likely to be covered under Medicare.

If an optometry provider suspects that Medicare may not cover a certain service or procedure, they must obtain a signed ABN form from the patients. It makes sure that when Medicare rejects claims, the beneficiary is liable to pay the practitioner. Failure to get the ABN signed before providing the service could result in not getting paid for the services. Filing a claim along with the ABN form ensures that providers do not lose out on getting reimbursed for the services they provide.

There are certain scenarios in which beneficiaries are not considered responsible for payments denied by Medicare. Hence, when Medicare denies payments, beneficiaries can choose to file an appeal if they are not satisfied with the decision. If the appeal by the beneficiary is valid, providers lose out on getting reimbursements for their services.

Healthcare providers can avoid the possibility of appeals by making sure that -

  • ABN is not difficult to read or understand

  • ABN is signed by the patient before providing the service or item

  • ABN mentions the exact service that was provided to the patient

  • The item or service they are offering is not specifically excluded from Medicare coverage

As of 1st January 2021, healthcare providers are required to comply with the updated instructions and rules while issuing ABN. The new guidelines apply to dually eligible individuals who have enrolled through the Qualified Medicare Beneficiary (QMB) and also enjoy Medicaid coverage.

As per the updated guidelines, dual-eligibles must be instructed to check Option Box 1 on the ABN for a claim to be submitted for Medicare adjudication. Similarly, there are also a few edits required in Option Box 1 as pr