A physician or supplier often has a lot of doubts when it comes to ambulance transports and ABNs. Most suppliers consider ABNs a way to avoid Medicare ‘medical necessity’ denials. So let’s dive deeper into a detailed understanding of ABNs, and their appropriate use. ABNs are only rarely appropriate for ambulance services. A physician or supplier may not shift liability to a beneficiary (who is under great pressure) by giving them an ABN. ABNs given to any individual who is under great pressure cannot be considered to be proper notice. It’s contradictory to the purpose of advance beneficiary notice. The purpose of ABN is to facilitate an informed consumer decision, on whether or not to receive an item or service and pay for it out-of-pocket.
A physician or supplier can’t obtain beneficiaries’ signatures on ABNs during medical emergencies and other compelling, coercive circumstances where a rational, informed consumer decision cannot reasonably be made. For that reason, physicians and suppliers may not use ABNs to shift financial liability to beneficiaries in emergency care situations. Ambulance companies may not give ABN-Gs to beneficiaries or their authorized representatives in any emergency transport because such beneficiaries are under great pressure.
When ABNs May Be Used
The Advance Beneficiary Notice (i.e., form CMSR-131-G) is appropriate for use in the case of ambulance services only when denial of the claim is expected under the ‘not reasonable and necessary’ program.
An ABN may be needed and may be used for non-emergency transports in the following situations:
- A transport by air ambulance when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by ground ambulance transportation.
- A level of care downgrade, e.g., from Advance Life Support (ALS)-2 to ALS-1, or from ALS to Basic Life Support (BLS), when the transport at the lower level of care is a covered transport.
- A transport from a residence to a hospital for a service that can be performed more economically in the beneficiary’s home.
- A transport of a skilled nursing facility patient to a hospital or to another SNF for a service that can be performed more economically in the first SNF.
When ABNs Should Not Be Used
An ABN isn’t needed and should not be used in the following situations:
- Any denial where the patient could be transported safely by other means.
- Any denial that is based on not meeting an origin or destination requirement.
- A denial for mileage that is beyond the nearest appropriate facility.
- A denial where the Physician Certification Statement or accepted alternative (e.g., certified mail) is not obtained.
- A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs but wants to be transferred to a second hospital to be closer to family.
Not obtaining an ABN in these ‘technical denial’ situations does not prevent the supplier or provider from collecting denied charges from the beneficiary. Note that the ambulance supplier cannot give an ABN and cannot shift liability to the beneficiary under Limitation on Liability (LOL).
The NEMB Option
CMS developed the Notice of Exclusions from Medicare Benefits (NEMB, optional form CMS-20007) to assist suppliers and providers in informing beneficiaries that the services they are receiving are excluded from Medicare benefits. Ambulance suppliers may develop their own process to communicate to beneficiaries that they will be billed for excluded services for which the ABN is not appropriate; the NEMB process is entirely voluntary. On the NEMB, check Box #1 and write the relevant reason in the ‘Medicare will not pay for’ space. For example, ambulance transports that do not meet an origin or destination requirement or ambulance transports where the patient could be transported safely by other means, or personal convenience transports.
Medical Necessity Denial
The ABN is unnecessary and inappropriate and should not be used. Any denial of an ambulance service that does not meet the definition of the Medicare ambulance benefit cannot be a ‘medical necessity denial.’ An ambulance service must first be a covered Medicare benefit before it can be denied under the ‘medical necessity’ exclusion in the case of a specific individual on a particular occasion. Most ambulance denials, therefore, actually are ‘technical denials.’ Confusion about the term ‘medical necessity’ arises because, when we in CMS speak of denial for ‘medical necessity,’ they usually are referring to the Medicare program exclusion. Therefore, an ambulance service that is ‘not medically necessary,’ means an ambulance service that is a covered Medicare benefit but not ‘medically necessary’ for that individual on that occasion.
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