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 providers cannot bill the dual-eligible beneficiary until adjudication by both Medicare and Medicaid.
Modifiers are necessary to provide additional information while processing a claim. They help in determining why an eyecare professional provided a specific service or item to the beneficiary.
Modifiers GA and GZ are used for services or procedures that are not deemed necessary by Medicare. On the other hand, modifiers GX and GY are used for statutory exclusions such as eyeglasses, eye examinations, etc.
The GA modifier indicates that an ABN is on file. It means the providers are enabled to bill the patient when a service is not covered by Medicare. This makes sure that if a claim is denied by Medicare, the liability will automatically be transferred to the beneficiary.
The GZ modifier comes into the picture when an item or service is expected to be termed as unreasonable or unnecessary by Medicare. This is an informational modifier only. It indicates that you do not have an ABN signed by the beneficiary and expect Medicare to reject the claim.
The purpose of the GX modifier is only to indicate that a voluntary ABN was issued for services excluded from Medicare. Claims that have the GX modifier applied to any covered charges are automatically denied by Medicare.
The GY modifier is used to obtain claims denial for excluded or non-covered eye care services. It simply notifies Medicare that the service provided is not covered under Medicare.
Are you looking to maximize reimbursements and ensure a positive cash flow for your optometry practice? CS EYE’s optometry billing services can help you maintain Medicare compliance and help you in protecting your profit margins. Get in touch to know how CS EYE can help your practice enjoy the benefits of minimum denials and maximum ROI.