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Advanced Beneficiary Notice (ABN)

During or prior to your stay, you may be asked to sign an Advanced Beneficiary Notice. This is a form that lets you know that you may have to pay for a test/services that your doctor has ordered if Medicare refuses to pay for it. Once you sign the ABN, JMH may bill you for the cost of the test. Below, for your information, are some commonly asked questions and answers regarding the ABN.

Q: Why do you want me to sign the ABN?

A: Although Medicare pays for most tests/services, it might not pay for some tests under certain circumstances. Consequently, we ask the patient to sign an ABN whenever it appears that Medicare is likely to deny payment for the specific test the doctor has ordered. The reason you are being asked to sign an ABN now is that this is one of those occasions that we or your doctor believe Medicare won’t pay.

Q: Why don’t you think Medicare will pay for this test?

A: Medicare pays only for tests that it considers to be “medically necessary.” Some tests are NEVER considered “medically necessary.” Some tests are ALWAYS considered “medically necessary.”

Most tests fall in the middle; they are medically necessary only under certain circumstances, depending on the patient’s diagnosis. If the diagnosis the doctor lists is not one of the diagnoses Medicare will accept for that test/service, the test/service will not be considered medically necessary, and Medicare will not pay for it. That appears to be the case with the test/service your doctor has ordered.

Q: If Medicare says the test/service is not medically necessary, then why perform it?

A: Your doctor has made a medical judgment that you need the test/service. When your doctor says a test is medically necessary, he/she considers your personal medical history, any medications you may be taking, and generally accepted medical practices. When Medicare says a test/service is not medically necessary, it is not making a medical decision about your health. It is acting like an insurance company deciding what it will and will not pay for. And, just like private insurers, there are occasions when Medicare won’t pay for services that doctors think are important to a patient’s health.

But as the ABN says, you have the option not to have the test/service done. If you have any questions about a specific test/service that your doctor has ordered for you and why it is medically necessary, ask your doctor.

Q: Must I sign the ABN?

A: No. You have three options.

Option 1: You may sign the ABN and have the test/service performed. You can then be billed for the test/service.

Option 2: You can refuse to sign the ABN and choose NOT to have the test performed. However, if you choose NOT to have the test performed, we advise you to consult with your doctor before choosing this option.

Option 3: You can refuse to sign the ABN and have the test performed. JMH will perform the test and you will receive a bill even though you refused to sign the ABN. A witness will sign the ABN to indicate you have been advised of the ABN, refused to sign it, but still want the test performed. Under Medicare guidelines, JMH can then bill you directly for the test.

Q: Is Medicare more or less likely to pay if I sign?

A: Neither. The fact that you signed an ABN will not affect Medicare’s decision either way.

Q: Will supplemental insurance pay for the test if Medicare does not?

A: Maybe. If you have a supplemental insurance policy, contact that insurance company directly and ask whether the policy will cover the test not covered by Medicare. If so, find out how to submit claims for payment under that policy.

Q: Must I sign an ABN each time a new test is done?

A: No. You will be asked to sign an ABN only when the provider has good reason to think that Medicare will deny payment for the ordered test. There may be visits to the doctor’s office or lab when you’ll be asked to sign an ABN and other visits when you won’t. It all depends on the test and the reason for ordering it on that visit.

Q: I’ve never had to pay for a test/service before. Is this something new?

A: The ABN isn’t new. It has been around for ten years. More hospitals are using it now because of recent changes in how Medicare pays for tests/services.

Q: What are the reasons I may be asked to sign an ABN?

A: There are several reasons you may be asked to sign an ABN.

Here are some examples:
  • Your doctor ordered different tests on previous visits. This is the first time he/she has ordered this test.
  • This is the same test your doctor ordered before, but your diagnosis has changed. The doctor is ordering this test for a different reason.
  • This is the same test and the same diagnosis, but Medicare has changed the rules and no longer pays for the test under this diagnosis.

For additional information regarding the ABN, please contact Customer Service at (860) 684-8452.

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