Non-Covered Services [Healthcare Compliance Tips]

Evaluate insurance company’s guidelines on non-covered requirements and create policies.

In our series called “Dear Provider: Don’t Give Up,” our last tip highlighted the issue physicians have with insurance companies and patient frustration.

And, another reported battle with non-clinical skills are:

Non-Covered Services

Understanding non-covered services is part of your non-clinical duties, which includes reviewing government and commercial insurance guidelines.

Each insurance company has their rules, but you will find some follow CMS guidelines closely.  CMS requires a non-covered form, called an Advanced Beneficiary Notice of Noncoverage (ABN), to be completed as a protection for their beneficiaries.

Let’s discuss the requirements of an ABN, such as:

• An ABN must have a clear reason the physician anticipates the service not being covered by Medicare. The form is not required for normal services that are excluded.
• If the ABN is not signed by the patient and Medicare decides not to cover the service, the charge is considered a write-off.
• Each procedure must have a separate ABN. A “blanket” ABN is never accepted.
• Modifiers must be applied to alert Medicare an ABN was signed. Keep a copy for your records and provide the patient a copy.

Understanding non-covered services and ABNs will play a role in building an effective compliance program.

You don’t want to risk patient complaints to the OIG.

Use CMS guidelines and the information above when creating ABN policies and procedures for your practice.

**The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify and tailor the advice to fit your specialty.