Billing and Coding: What is the ABN Form and Why Do I Need It?

DCs may often find themselves needing to submit an ABN form for Medicare patients. When do you need it - and when don't you?

Posted in Examiner eNewsletter on Wednesday, August 25, 2021

The ABN, or Advance Beneficiary Notice, is a form that is intended for only for Medicare beneficiaries – not Medicare advantage plans or Medicare part C, just true Medicare. 

Medicare will only pay for a service if they can see that the patient has made progress through treatment. If you and your patient decide to continue adjustments just for maintenance or supportive care, but not to treat a specific issue, you have to notify your patient that Medicare is no longer going to cover the cost of their adjustments.

This notification must include providing your patient an ABN form. “You say to them, look, you and I both agree that you're going to get adjusted, but Medicare is not going to pay for it because you're not progressing,” says Dr. Evan Gwilliam, clinical director for PayDC Chiropractic Software. “Fill out this form that shows that you understand that and you accept the fact that you need to pay for this.” At this point, Dr. Gwilliam says, your patient can also opt to have you send it through Medicare to see if it will get paid or denied.

What About Patients Who Don’t Have Medicare?

The ABN form, specifically, is for Medicare use only. For your patients who have insurance through a company like United or Blue Cross, those insurance companies may have similar forms that you will need to submit – but the ABN form is restricted to Medicare only. If your patient’s insurance company doesn’t have a form that notifies patients about non-coverage, Dr. Gwilliam strongly advocates making your own.

The form should include:

• A description of the services being provided that will likely not be covered by their insurance
• The cost of those services.
• The patient's signature, indicating that they understand that they will be responsible for the payment out-of-pocket. “

"That will save you all kinds of headache and people who could potentially file a claim against you because they feel like they didn't understand if you disclose everything,” Dr. Gwilliam says. “In my opinion, it really helps with liability.”

For the answers to more billing and coding questions, check out our two-part webinar series, “Potential Errors in Billing and Coding."