QUESTION: I have two questions regarding Medicare. First, I heard from a colleague that Medicare is requiring a new Advance Beneficiary Notice (ABN). When is the new notice required and where is it available? Second, I understand I have reductions based on electronic health records and reporting of outcome measures, but I continue to see a reduction, I believe 2 percent, off my Medicare payments. The reason given by Medicare is CO-253, "sequestration – reduction of federal payment." What is this and is there a way to recoup this deduction from the patient or secondary?
The New ABN
Medicare has updated the ABN and the newest version is required after June 21, 2017. The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by physicians, practitioners and suppliers to original Medicare (fee-for-service) beneficiaries when Medicare payment is expected to be denied.
For chiropractors, it must be used when manipulation is or is likely to be determined by Medicare as maintenance. Once the patient has signed the form, the manipulation code may be billed with modifier GA to indicate the ABN is on file and signed by the patient, in which they have agreed and understand their personal responsibility for the spinal manipulation service.
The form itself has no major changes, but does now include language informing the Medicare beneficiary of their rights to non-discrimination and how to request an ABN in an alternative format if needed. You will also note the new expiration date of March 2020.
This updated notice can be downloaded in English and Spanish versions (with an instruction manual) at https://www.cms.gov/medicare/medicare-general-information/bni/abn.html.
What is maintained on this updated ABN is that when the patient chooses option 2, you need not send a claim or bill to Medicare. The patient simply pays directly. This applies to participating "par" providers, not only to non-participating or "non-par" providers. However, the amount you may charge remains the Medicare allowable fee for spinal manipulation and may not be at your regular rate.
Fee Reductions
As for the reduction of fees, here is a clear example of how the timely passing of a budget (or lack thereof) by Congress – and what it enacts to balance the budget – impacts your practice. Due to the Budget Control Act of 2011, there was a mandatory reduction of federal spending, known as sequestration. This reduction is noted on a Medicare remittance advice (EOB) under reason code CO-253.
Medicare fee-for-service claims with a date of service on or after April 2013 incur a 2 percent reduction in Medicare payment. This reduction or claims payment adjustment is applied to all claims after determining coinsurance, any applicable deductible and any applicable Medicare Secondary Payment adjustments.
Although beneficiary payments for deductibles and coinsurance are not subject to the 2 percent reduction, Medicare's payment to beneficiaries for unassigned claims is subject to the reduction. This means the patient will not receive the 80 percent of the non-par rate, but an amount reduced 2 percent.
For assigned claims, the patient will maintain their same copayment and amounts applied to deductible, but the payments made to the provider will be reduced 2 percent. These amounts cannot be transferred to or collected from the patient.
Medicare has just published (April 20, 2017) that this reduction will continue at minimum to the end of the year. Bear in mind that this reduction affects all Medicare payments, not just those for chiropractors, including all fee-for-service payments for drugs, health care items (DME) and services.
Editor's Note: Feel free to submit billing questions to Mr. Collins at sam@hjrossnetwork.com. Your question may be the subject of a future column.
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