Medicare Ambulance Transports and ABNs

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Medicare Ambulance Transports and ABNs
A physician or supplier often has a lot of doubts
when it comes to ambulance transports and ABNs.
Most suppliers consider ABNs a way to avoid
Medicare medical necessity denials. So lets
dive deeper into a detailed understanding of
ABNs, and their appropriate use. ABNs are only
rarely appropriate for ambulance services. A
physician or supplier may not shift liability to
a beneficiary (who is under great pressure) by
giving them an ABN. ABNs given to any individual
who is under great pressure cannot be considered
to be proper notice. Its contradictory to the
purpose of advance beneficiary notice. The
purpose of ABN is to facilitate an informed
consumer decision, on whether or not to receive
an item or service and pay for it
out-of-pocket. A physician or supplier cant
obtain beneficiaries signatures on ABNs during
medical emergencies and other compelling,
coercive circumstances where a rational, informed
consumer decision cannot reasonably be made. For
that reason, physicians and suppliers may not use
ABNs to shift financial liability to
beneficiaries in emergency care situations.
Ambulance companies may not give ABN-Gs to
beneficiaries or their authorized representatives
in any emergency transport because such
beneficiaries are under great pressure. When
ABNs May Be Used The Advance Beneficiary Notice
(i.e., form CMSR-131-G) is appropriate for use in
the case of ambulance services only when denial
of the claim is expected under the not
reasonable and necessary program.
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Medicare Ambulance Transports and ABNs

• An ABN may be needed and may be used for
  non-emergency transports in the following
  situations
• A transport by air ambulance when the
  transporting entity has a reasonable basis to
  believe that the transport can be done safely and
  effectively by ground ambulance transportation.
• A level of care downgrade, e.g., from Advance
  Life Support (ALS)-2 to ALS-1, or from ALS to
  Basic Life Support (BLS), when the transport at
  the lower level of care is a covered transport.
• A transport from a residence to a hospital for a
  service that can be performed more economically
  in the beneficiarys home.
• A transport of a skilled nursing facility patient
  to a hospital or to another SNF for a service
  that can be performed more economically in the
  first SNF.
• When ABNs Should Not Be Used
• An ABN isnt needed and should not be used in the
  following situations
• Any denial where the patient could be transported
  safely by other means.
• Any denial that is based on not meeting an origin
  or destination requirement.

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Medicare Ambulance Transports and ABNs

• A denial for mileage that is beyond the nearest
  appropriate facility.
• A denial where the Physician Certification
  Statement or accepted alternative (e.g.,
  certified mail) is not obtained.
• A convenience discharge, e.g., where the patient
  is an inpatient at one hospital that can care for
  their needs but wants to be transferred to a
  second hospital to be closer to family.
• Not obtaining an ABN in these technical denial
  situations does not prevent the supplier or
  provider from collecting denied charges from the
  beneficiary. Note that the ambulance supplier
  cannot give an ABN and cannot shift liability to
  the beneficiary under Limitation on Liability
  (LOL).
• The NEMB Option
• CMS developed the Notice of Exclusions from
  Medicare Benefits (NEMB, optional form CMS-20007)
  to assist suppliers and providers in informing
  beneficiaries that the services they are
  receiving are excluded from Medicare benefits.
  Ambulance suppliers may develop their own process
  to communicate to beneficiaries that they will be
  billed for excluded services for which the ABN is
  not appropriate the NEMB process is entirely
  voluntary. On the NEMB, check Box 1 and write
  the relevant reason in the Medicare will not pay
  for space. For example, ambulance transports
  that do not meet an origin or destination
  requirement or ambulance

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Medicare Ambulance Transports and ABNs
transports where the patient could be transported
safely by other means, or personal convenience
transports. Medical Necessity Denial The ABN is
unnecessary and inappropriate and should not be
used. Any denial of an ambulance service that
does not meet the definition of the Medicare
ambulance benefit cannot be a medical necessity
denial. An ambulance service must first be a
covered Medicare benefit before it can be denied
under the medical necessity exclusion in the
case of a specific individual on a particular
occasion. Most ambulance denials, therefore,
actually are technical denials. Confusion about
the term medical necessity arises because, when
we in CMS speak of denial for medical
necessity, they usually are referring to the
Medicare program exclusion. Therefore, an
ambulance service that is not medically
necessary, means an ambulance service that is a
covered Medicare benefit but not medically
necessary for that individual on that
occasion. Medical Billers and Coders (MBC) is a
leading medical billing company providing
complete medical billing and
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Medicare Ambulance Transports and ABNs
coding services. If you are receiving medical
necessity or other denials, we can assist you.
Our ambulance billing billers are well-versed
with coverage guidelines and payer reimbursement
policies which ensure accurate insurance
reimbursement. To know more about our ambulance
billing and coding services, call us
at 888-357-3226 or email us at info_at_medicalbille
rsandcoders.com. Reference The Medicare
Ambulance Benefit Statutory Bases for Denial of
Claims