Find-A-Code Focus Newsletter

ABN's, Third Party Payers, and Cash Pay

March 08, 2016
Medicare no longer wants providers to use ABN's for anyone other than CMS. Therefore, if contracted under commercial payers and 3rd party payers, you may need to contact the payer for a pre-service organization determination regarding coverage. This must be done before the provider can perform the service and bill the beneficiary for non covered services. To ensure compliance with Federal Medicare regulations and guidelines, be sure you contact your 3rd party payer if you are unsure on how to proceed.

If there is a contract in place, you may only be able to bill the patient for co-pays and deductibles the patient would normally have to pay. Once a patient tells you they are covered under a plan which you are contracted with, you may be legally required to bill the payer. If the patient does not tell you they have coverage, I suggest to have them sign an insurance waiver stating they do not have coverage and want to pay cash for your services. This may also be helpful if they go back and change their mind, so you don't run into any legal issues.  

Some payers state in their contracts that it is mandatory to bill them, regardless of coverage.  There may be circumstances where a patient may sign a WAIVER TO FILE INSURANCE, again all payer specific.  Remember, legally providers cannot waive, reduce, or discount any co-payments, deductibles or co-insurances, if they are contracted.
If you do have an ABN on file you need to inform Medicare using the informational modifiers. Be aware some modifiers will increase of decrease reimbursement.

For certain payers, be sure to use the pre-service organization determination process in place of either issuing ABNs or including ABN -specific modifiers on services or items supplied to MA members to ensure compliance.


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