Advanced Beneficiary Notices

Advance Beneficiary Notices, better known as ABNs, are forms that are a requirement from Medicare that informs the patient that a particular procedure they may be able to undertake will not be covered by Medicare. Some other insurances are starting to institute this also, but it's mainly a Medicare requirement.

Both hospitals and participating physicians are required to tell you in a procedure won't be covered under certain diagnosis codes. The ABN is an acknowledgement that they told you, and they will request you to sign it. Whether you sign or not will not make you less responsible for the item if you decide to go ahead with the procedure. Sometimes Medicare will pay it if it turns out there were mitigating circumstances, or if the physicians didn't include all the codes to indicate the reason for the extended test, but otherwise it's very unlikely that Medicare will change its mind. The wording is supposed to be definite, not "may not cover", and if this form was not presented to you at the time of registration, a hospital might have to adjust the procedure off on the back end.

The overwhelming majority of procedures that this covers are lab procedures, where physicians may request multiple items be checked by only provides one diagnosis code that may not cover them all. Often, instead of completing an ABN, a call to the physician's office will get an additional diagnosis code that will cover those tests. The same thing might apply for other procedures, so it's always a good thing to check back with your physician if you can. However, if they tell you up front that a procedure won't be covered, regardless of the diagnosis code, then the claim won't be paid at all.

As the patient, you always have the right to request that the medical entity bill the claim anyway, just to make sure it's not going to be covered. Also, it would be a good thing to verify with your secondary insurance, if you have one, that they'll cover the procedure if Medicare doesn't, because often, if a procedure is being denied because of the diagnosis code, they won't cover it either.