Reporter's notebook: Cash customer? ABN still gold standard

With more and more providers switching their focus from Medicare to cash sales, it's unsurprising that there's occasional confusion about whether an advance beneficiary notice is needed.

HME News recently received an email from a small DME supplier that has not billed Medicare in four years and recently learned they still needed to complete ABNs for all Medicare beneficiaries.

“We have people come into our business that have Medicare but are choosing to pay out of pocket because they don't want to have to dealt with obtaining all the necessary documentation from their physician and the time it may take,” wrote the provider. “We recently tried to 'opt out' of Medicare but were told that if we go this route, we cannot sell to Medicare beneficiaries at all. We have to turn down the business because they are legally entitled to use their Medicare.”

Recognizing this as a question that comes up frequently, HME News turned to the experts.

If a provider has any reason to suspect the product is for a Medicare beneficiary, then yes, you need to go through the ABN process, says Andrea Stark, a reimbursement consultant with MiraVista.

“Suppliers don't get the luxury of turning a blind eye and assuming the patient doesn't have Medicare,” she said. “It doesn't matter who you are, whether you are participating or, non-participating or even if you don't have a Medicare number at all, you would have to file a claim for all covered services and benefits.”

That's because the government will always err on the side of protecting the beneficiary, says Stark.

“The supplier needs to be the expert in the transaction,” she said. “The burden is never intended to shift to the patient for them to navigate their own insurance.”

Some providers may decide it's worth the risk to forgo the ABN, but they run the risk of having to refund the money if that patient changes their mind, says healthcare attorney Lisa Smith.

“If a 70-year-old woman buys a rollator and then finds out her friends all had theirs paid for by Medicare, she wonders, why did she pay cash?” said Smith, a shareholder with Brown & Fortunato. “The gold standard is to get an ABN signed by the patient.”