Advance Beneficiary Notices (ABNs) – Overview & Process
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, plays a significant role within the laboratory testing process. It is used to inform a patient that a laboratory service may not be covered by their insurance.
This allows the patient to acknowledge and accept potential financial responsibility before the service is performed.
This does not mean there will be a charge, but it provides notice that a charge may occur if the diagnosis provided is not covered, frequency limits are exceeded, or other payer guidelines are not met. It is also sometimes used in scenarios where a patient or resident may not have insurance, suspects a denial, or wishes to take responsibility for any payment.
For example, in the event a patient is insistent on having a lab test performed, and there is no medically necessary diagnosis according to Medicare, a signed ABN should be provided in advance. An ABN must be completed and signed each time a lab order is placed when applicable. The completed ABN form should be submitted with the lab order.
Is an ABN form needed to bill a patient?
Yes, Aculabs has implemented this process to ensure compliance with billing regulations and to clearly define financial responsibility. When a valid ABN is on file, responsibility for any denied claim can be transferred to the patient. If an ABN is not obtained and the claim is denied, the facility will be held financially responsible, and the balance will be billed to the facility – not the patient.
The Centers for Medicare & Medicaid Services (CMS) holds well-established guidelines regarding what is considered medically necessary within the realm of testing, so ABN forms avoid issues like “surprise billing” by making it clear to the beneficiary that they may have to pay for a test if Medicare will not pay for it.
For example, if Medicare denies payment due to overutilization, Aculabs will bill the facility unless an ABN signed by the beneficiary was provided