Have ABNs become 'gray area'?

WASHINGTON - The proper use of advance beneficiary notices (ABNs) has shifted—and not in the HME provider's favor, industry stakeholders say.

CMS has evolved its policy to the point where providers can no longer use ABNs to “upgrade” within the same code, says Andrea Stark, a reimbursement consultant with MiraVista.

“We are operating in gray areas,” she said. “It has definitely been an erosion of how we utilize this.”

Case in point: In January, the PDAC expanded the definition of mastectomy bras to include the words “any size, any type.” That makes it very difficult to justify an upgrade, Stark said.

Other products will soon feel the effects of CMS's new position on ABNs, stakeholders say.

“The ripple effect is going to be widely felt,” Stark said. “I haven't seen mass education in other policies, but I don't think we're far from seeing that emerge throughout.”

What are providers to do? They can bill claims non-assigned, says Bruce Brothis, president of Allegient Billing & Consulting. This requires a provider to be categorized as non-participating with Medicare, he said.

“Outside the competitive bidding areas, the patient can pay you full retail upfront, then you submit a claim to Medicare to get the patient reimbursed 80% of the Medicare allowable,” Brothis said.

The competitive bidding wrinkle

Contract suppliers in competitive bidding areas also have to deal with the non-discrimination clause when using ABNs.

“Items furnished by contract suppliers must be the same as those offered to other customers,” said Marshall Meringola, an attorney with Amarillo, Texas-based Brown and Fortunato. “They want to make sure beneficiaries under competitive bidding have access to the same products all other Medicare beneficiaries and private pay customers have access to.”

What that means: Even if contract suppliers offer good, better, best options, they're going to get paid the same, stakeholders say.

Contract suppliers can set up separate retail companies to offer upgraded products—but they must dot their i's and cross their t's, says consultant Jack Evans.

“Medicare requires that the retail store must have a different name so as not to confuse Medicare patients that the retail store still bills Medicare,” said Evans, president of Malibu, Calif.-based Global Media Marketing. “(The retail locations also need) a separate physical address and a separate tax ID/corporate entity.”