Each year Medicare offers around 6 or more basic services for beneficiaries and provides coverage as seen fit. Aside from the basic services, enrollees may feel the need to have access to more based on their needs which may result in no coverage from Medicare and paying the full expense. Luckily, health care providers issue Advance Beneficiary Notices (ABNs) to Medicare beneficiaries to advise them that the services being provided may not be covered by Medicare. Each notice, which is also called a Medicare waiver or a waiver of liability, transfers the legal responsibility to pay for the services from Medicare to the beneficiary. Dealing with health care finances can be a tedious task, being informed on what is accurate to you is essential.

Is Medicare Advantage Subject to an ABN?

Private insurance companies manage Medicare Advantage plans. As a result, you will not receive an Advance Beneficiary Notice for your services if you are covered by an Advantage plan. Only beneficiaries with Original Medicare receive ABNs.

What Information Can You Expect an ABN to Include?

Medicare decides what information should be included on an ABN. It also controls the procedures that are ABN-eligible. If your provider does not follow Medicare’s rules for ABNs, you may not be liable for the payment of the services.

All ABNs must include the following information:

  • Your first and last name.
  • The contact information of the provider, including their name, phone number, and address.
  • The procedure that is in question.
  • The reason the procedure may not be covered by Medicare.
  • The estimated charge for the service.

There are also other guidelines that govern ABNs which include:

  • An ABN form cannot be more than one page in length. However, attachments are permitted for certain procedures.
  • The form must be easy to read, and the provider must make sure that you understand what the ABN states.
  • Your provider must answer any questions you have concerning the information on the form.

Can a Doctor Issue an ABN, Regardless of Your Medical State?

Providers are not allowed to issue an Advance Beneficiary Notice to you if you’re in an emergency situation or feel pressured to sign the form. Thus, it is not legal for a provider to present you with an ABN if you are en route to the hospital or in an emergency room in the middle of an acute medical crisis.

Moreover, you must have enough time between the receipt of the ABN and the performance of your procedure to think about what you are signing and what your other options may be. If your provider does not adhere to Medicare’s guidelines concerning the issuance of an ABN, you are not liable for the charges—even if the claim is denied.

When Are You Not Liable for the Charges on an ABN?

You are responsible for your copayment alone if Medicare covers the charges on the ABN. If Medicare denies the charges, you are still not liable if:

  • The ABN is not legible or is difficult to understand.
  • The provider gives ABNs to all their patients without explaining why the charges are likely to be denied.
  • The ABN does not identify what service is being provided.
  • The beneficiary signs an ABN after receiving the service.
  • The ABN is offered in the middle of a medical emergency.
  • The ABN is given to you immediately before your procedure.

What Are Your Options if You Get An ABN?

Once your doctor gives you an ABN, you have several choices. Your three options, which are listed next to checkboxes on the ABN notice, include:

  1. You want the services listed on the form and would like Medicare to be billed. You may decide that you want the services that your provider is offering, even though there is a possibility that Medicare will not cover the charges. This option lets the provider know that you still want them to bill Medicare. If Medicare does deny your claim, you can appeal the decision. If the provider receives payment from Medicare and you paid upfront for the services, the provider must refund the difference between your payment and your copay or deductible.
  2. You want the services but don’t want to bill Medicare. The provider may ask for payment for the services upfront. However, unlike the first option, with this selection, Medicare won’t receive a claim form. Additionally, with no claim filed, the Medicare appeal process is not available to you.
  3. You don’t want the services listed. With this option, you choose to refuse the services and are not responsible for the associated charges.