Best Practice Commercial ABN Waivers. September Lake Morey Inn and Resort YOUR REVENUE CYCLE

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1 Best Practice Commercial ABN Waivers September Lake Morey Inn and Resort YOUR REVENUE CYCLE Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC

2 Overview What are Commercial Waivers? How to complete a Commercial Waivers? LCD vs. NCD do Commercial payers have these? Do commercial insurance take Waivers?

3 What is waiver form? It is a customized written document used to inform the patient that a specific service (s) ordered for their care may not be a covered service. Waiver indicates the patient s agreement to accept responsibility for payment in the event insurance denies payment

4 What is the purpose of a financial waiver form Financial waiver forms provide notification to patients about the practice's expectations regarding insurance coverage for a specific service. Providers and facilities utilize them when they believe or know that the item or service is not covered or may not be covered. They provide patients with the option to receive the service and, by signing the waiver form, agree to be financially liable if the item or service is denied coverage.

5 What are the key components to include on the financial waiver form for a non-medicare patient? There are several. They include: 1) Identify the service or item. 2) Explain why you believe it may be denied or is noncovered. 3) Provide a service or item cost estimate. 4) Provide a statement that indicates the patient's agreement to pay if service or item is denied. 5) Provide a signature line for the patient to sign and date. Commercial payers may or may not require financial waiver forms. Your participation contract may include a provision requiring notification to patients when you believe items or services will be non-covered. Check with the individual payer.

6 If my contract doesn't require waivers, why would I voluntarily use them? There are a few good reasons. Many patients believe that insurance covers all services. We know this is wrong, but ensuring that all parties are on the same page about coverage is a good idea. Waiver forms validate that the patient was informed and agreed to compensate you for the service provided in the event of a denial. Patients "forget" that you told them and may plead that they were not informed to the insurance company. If the payer believes the patient was not informed and had no way of knowing of a potential denial, it could waive the patient's liability. A signed waiver usually negates the patient's appeal to the payer.

7 Are ABNs for Medicare only? No. You can also have a patient sign a Waivers/ABN for a private payer. This helps the patient to understand that if their insurance doesn t cover the service specified, the patient will have to pay for it. Medicare requires an ABN be signed in order to bill the patient, but for patients with private insurance it s still a great opportunity to talk about non-covered services, deductibles, copays, coinsurance or any past balances if you haven t already. A few private payers actually require a waiver/abn to bill patients for noncovered services check your contract to be sure.

8 We are a small, busy practice; that sounds like a lot of work! It is a lot of work for a practice! Many practices choose to not use the Waivers/ABN rather then work out a protocol to implement it. The practice has to have system in place so that the physician or staff member can explain the situation, fill out the form, answer the patient s questions and file the Waivers/ABN for posterity (they have to be kept seven years, like other records). It can be the physician in a micro-practice, or a dedicated billing or customer service employee in a larger setting. Also, a note has to be made of the Waiver/ABN signing in the patient s chart so that modifiers can be added to the CPT codes for billing. if dx code changes during this time, a new Waiver/ABN may be needed. I would not suggest getting an Waiver/ABN to cover a 12 month period for any service, know this is the reg but realistically how is the front desk, provider, etc.. for example going to know the patient signed a waiver for this particular service 2 months ago,.

9 Commercial Insurance Some insurance companies call them Waiver Forms This would be completed like an ABN. This form can look like Medicare's ABN form or the insurance company can design their own. they have to be kept seven years, like other records

10 Waivers/ABN filing Original signed and dated ABN is filed in the clinic chart or if it is an EMR it should be stored in a retrievable fashion. A copy is to be provided to the patient. A copy is to be attached to the patient s corresponding charge ticket for charge entry purposes.

11 Correct completion of Waivers/ABN form Patients name must be filled in completely. DO NOT PUT PATIENTS LABEL STICKERS ON THE FORM Identification number is to help link the notice with a claim. You can use the account number but the field is optional. The beneficiary s Medicare number or HICN should no longer be used. Description of service (s) that may be denied must be understandable to the patient. An explanation of the reasons (s) for potential denial. (Reasons such as we don t know why they might not pay for it are not specific enough. Estimated cost column: The estimated amount must be listed. Use good faith estimate do not leave blank. Must check one of the boxes for the option. In Additional information notifiers can use the space to record other payer information. The patient or guarantor must sign and date the form.

12 Key features of Waivers/ABN form Have an official title, for the Advance Beneficiary Notice of Non coverage (ABN) to Waiver.. May also be used the Medicare ABN form after removing the CMS information on the form. Has a mandatory field for cost estimates of the items/services at issues. Include all options, where an individual may choose to pay out of pocket and submit claim to payer

13 COLLECTING PAYMENT FROM THE BENEFICIARY When a Waivers/ABN is required, if you properly notify the patient that the item or service may not be covered and he or she signs the form, you may seek payment from him or her.

14 National Coverage Determinations (NCD) NCD are a list of tests not covered by Medicare if the diagnosis is not listed on the NCD. Some payers have list on test that they look for medical nessicity I.e. Harvard Pilgrim and OB ultrasounds

15 ding-the-use-of-financial-waiver-forms

16 Questions?

17 Contact Today s Speaker Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC CEO/President robin@mrsnh.com Medical Reimbursement Specialists, LLC PO BOX Pleasant St Suite C Bristol, NH Office PHONE: (866) Cell Phone (603) FAX: (603)