Am I required to bill Medicare? Understanding the Medicare Advanced Beneficiary Notice

Many occupational therapy practitioners are used to providing cash-pay services to clients when the practitioner is out of network or the insurance denies a particular service. However, practitioners need to be careful with this practice when it comes to evaluating and treating Medicare beneficiaries. A Medicare beneficiary cannot be asked to pay for a service that may otherwise be covered by the Medicare program without obtaining a signed Advanced Beneficiary Notice of Non-Coverage (ABN) prior to performing the service.

Unlike commercial insurance, the Centers for Medicare & Medicaid Services (CMS), the agency that administers the Medicare program, does not allow an occupational therapy practitioner to see clients as out of network, as a non-Medicare provider. Any practitioner, even those who are not technically enrolled as Medicare providers, must directly bill CMS for any medically necessary skilled therapy services provided to Medicare-covered clients.

Medicare-covered clients are entitled, under law, to medically necessary services. Occupational therapy practitioners do not have the right, under current statutes, to “opt out” of Medicare, so the safest way to charge clients privately for services is to provide an ABN to the patient and have them sign it prior to rendering services, with the appropriate billing option selected on the form.

Deconstructing the ABN: How to complete the form

An ABN can be used in several circumstances. An occupational therapy practitioner may see a client for a service that would generally be covered under the Medicare program, but in this instance, the service may not be covered.

Examples

• A client is no longer in need of skilled therapy based on the clinical judgment of the physician and therapist but wants to continue receiving treatment out of fear that their skills will deteriorate without it.
• A Medicare beneficiary needs a replacement orthotic, but it has not been 5 years. The orthotic is usually covered by Medicare, but in this case, the requirement of replacement only after the reasonable useful lifetime of 5 years has not been met. (Although AOTA is advocating to change the 5-year rule, Medicare will most likely deny the orthotic service, and without a signed ABN, the client cannot be billed.)
• A request is made for a home safety evaluation for home modifications. Medicare will currently cover and reimburse for home safety evaluations as part of an occupational therapy evaluation, but if the request is preventative in nature, then the service may not be covered.

CMS provides the ABN form along with detailed instructions on completing it. If you are seeking services that are not covered under Medicare, you must indicate the specific service being provided in box D, the reason Medicare may not pay in box E, and the expected out-of-pocket cost to the patient in box F. When completing the ABN, you must detail the current services being provided and review the ABN with the client prior to the service being rendered. Blanket ABNs are not acceptable.

The client then must choose among the following:

• Option 1: Pay now and bill Medicare for the services
• Option 2: Pay now but do not bill Medicare
• Option 3: Refuse the services.

The occupational therapy practitioner should clearly explain each option but must allow the client or their representative to select an option without any influence from the practitioner. The practitioner must abide by the option selected.

Payment may be obtained upfront, but it must be refunded if Medicare pays any part of the service. If the client selects Option 1, a claim must then be filed with Medicare using a GA modifier to notify Medicare that an ABN has been obtained.

If Option 1 is selected and the practitioner is a Medicare non-participating provider, the instructions state that the practitioner is required to modify the ABN as follows:

Strike the last sentence in the Option 1 paragraph with a single line so that it appears like this: If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.

When this sentence is stricken, the practitioner shall include the following CMS-approved “unassigned claim” statement in the (H) Additional Information section:

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

AOTA strongly recommends that you closely review instructions for complete guidelines on completing all sections of the ABN form because they contain additional details. Following these guidelines ensures compliance with Medicare when billing patients for non-covered services. In doing so, occupational therapy practitioners can treat clients feeling confident they are appropriately billing for services rendered.

AOTA continues to work with occupational therapy practitioners to identify reimbursement barriers to providing medically necessary therapy to Medicare beneficiaries while also prioritizing quality care that is ethical and safe for vulnerable populations. AOTA, along with the American Physical Therapy Association and the American Speech-Language-Hearing Association, continues exploring legislative options related to the inability of therapy practitioners to opt out of Medicare.