Perhaps it’s because it’s the start of the year, or because I have my ChiroProgress Seminars coming up focusing on how to do better Medicare, better insurance and better business. Or perhaps because, we chiropractors simply still don’t understand the ABN.

Regardless, the questions are coming in.

And they tell something about many DC’s — you are doing the ABN’s wrong.  Here’s why:

The Small, But Powerful and Often Misunderstood ABN

The Advanced Beneficiary Notice (ABN) is perhaps one of the most misunderstood and mismanaged forms in the chiropractic office. For some practices, it’s a big burden that is pushed on patients with alarming frequency which unnecessarily tires out staff, sparks a bit of paranoia and patient confusion in its wake.

And yet, the fear of fumbling the ABN is not entirely unfounded. Incomplete or missing Advanced Beneficiary Notices can easily get you into hot water with Medicare and can lead to forfeiting dollars you have already been paid, fines, more audits, a bit more fear and if it’s a sign of really bad things: a pinstriped suit and a jail cell with a toilet that probably doesn’t flush.

A Simple Form That’s Apparently Not So Simple

On the surface, the ABN form appears deceptively simple. And if you truly understand how to use it, it certainly can be.

Unfortunately, I routinely field questions about the ABN at my chiropractic seminars and it’s apparent that things go awry in the actual application of the ABN form inside chiropractic offices.

From my reviews of chiropractors’ documentation that I perform in connection with chiropractic audit consult (when Medicare or some other payer gives you the letter), a random sampling typically reveals that many Medicare files feature ABNs that are blank, missing or mangled (incorrect info).

I wish I could say that this experience was a rare moment out of the many chart reviews I have performed, but it is not. To my surprise, MD’s are apparently not too swift at understanding the ABN either. Despite the old saying “misery loves company,” when it comes to substandard documentation, failure to adhere to Medicare policies and regulations, or downright fraud – it is much better to be a lone ranger.

Common Chiropractic ABN Errors

The ABN form clearly communicates its purpose to Medicare beneficiaries: it is an “Advance Beneficiary Notice” of Non-covered services. In other words, you are utilizing the ABN to inform the Medicare patient that you anticipate that Medicare will not pay, so that you can legally collect for services rendered.

What is not so clear in the eyes of many physicians (including chiropractors) is exactly HOW to use this form. To prevent the myriad of problems that may stem from an improperly administered ABNs, here are the most common errors that I see in a chiropractic setting:

Missing cost estimates. The cost estimate portion of the ABN is a mandatory field. This instruction differs from that for the prior version of the ABN, which noted that the estimated cost field was optional. CMS has stated that the provider must make a good faith effort to provide a reasonable estimate for those items and services listed on the ABN. CMS expects that an estimate fall within $100 or 25% of the actual costs, whichever is greater.  For Chiropractors, this should be a reasonably easy amount to estimate.  For example, if you are going to perform an adjustment that day that you anticipate Medicare may deny due to medical necessity issues, you can have the patient sign the ABN and the cost may be estimated in the range of your adjustment fees (i.e. you may not know beforehand how many areas you are going to adjust, but you know their fees and can give an accurate estimate of the range).

Routine Use of ABNs. Due to the fact that it is required that the ABN describe the particular service(s) and the particular reason(s) for the expected denial, it is unacceptable if the chiropractor routinely has all his Medicare patients sign the ABN every visit.  This is known as a “blanket ABN” and every Medicare carrier in the country frowns upon this as an attempt to cover your tail with one universally applied form. As a chiropractor, part of your job is to establish the medical necessity for your care. To simply assume that none of your visits will meet medical necessity either implies that you are not documenting your care or are practicing so far outside the norm (or scope?) of most chiropractors that you know that no one is willing to pay for what you do. Either situation is problematic in Medicare’s eyes.

Lack of Specific Reason For Denial. Too many ABN forms that I have seen lack specificity when it comes to stating a reason that you anticipate denial of your service. It is inadequate to simply state that “there is a possibility Medicare may not pay for the service.”  This is implied by your usage of the form! Instead, you should give the specific reason you anticipate denial. For example, “Medicare never pays for maintenance care” or “This is a service that is not covered when performed by a chiropractor.”

Missing Options. The new ABN form gives the patient three options to choose from in terms of receiving this service. Option One essentially states that they understand the service may not be paid, but the patient wants the service and wants you to bill it anyway. Option Two states that want the service, but that you don’t have to bother to bill it to Medicare. Option Three states they refused the service now that you have told them Medicare may not pay.  (And consequently, you cannot give that service to the Medicare patient). One of these three options must be checked if you are utilizing the ABN form.  Missing options represent an incomplete, and therefore invalid ABN form that can potentially get you in trouble if you received funds for services on this date.

Mandatory vs Voluntary Usage. Perhaps the most misunderstood aspect of the ABN is that is is required (mandatory) only for covered services. In chiropractic, our only covered service is the chiropractic adjustment that is rendered as a part of Active Treatment (AT Modifier) for correcting a subluxation. So if you anticipate a denial of your chiropractic adjustment because it is maintenance, then it is required that you inform your patient via the ABN. All other services (such as exams, x-rays, therapies, etc) are not statutorily covered services when performed by a chiropractor. Therefore, you are not required to give your patients an ABN for these services; in other words, any ABN given out for these circumstances is completely voluntary.

Getting It Right

The Office of Inspector General target the ABN for review because it is widely known that there are many mistakes being made (not only by chiropractors, but MD’s as well) that result in improperly administered ABN and incorrect payments as a result. ABN abuse would be an easy item for Recovery Audit Contractors to target upon their reviews of your files, so it is imperative you use the ABN specifically as it is indicated.

To see just how quickly the stakes add up, let’s just calculate a scenario similar to the one I discussed above where every ABN went unsigned and therefore improperly administered.

To give you a little credit, we will assume you had only 50% of your ABN’s incomplete and a review of your records reveals that this is the case.  With some quick extrapolation, auditors could decide that 50% of your entire Medicare patient base probably contained the same errors and after a few faulty reviews, they can extrapolate that 50% of all services were overpaid (unfortunately, you also had patients sign an ABN each and every visit).

Now go and do the math over the last three years (that is how far back the RACs will go in their reviews).  If 50% of all your Medicare payments were demanded back, how much would such a mistake cost you?

If you are still standing, now take a look from the other side of the fence.  How much easy money could a RAC gain in a post-payment audit from your mistake?  And, could they potentially recoup even more money from you from other errors related to your Medicare documentation, billing and coding?

Hopefully, this is enough money to impress upon you that it is high time to start getting serious about your internal policies and procedures.

Fix It Fast Action Steps

If you are committing any of the above errors, you’re likely costing your staff critical time, needlessly producing paranoia for patients (or staff or yourself) and/or you are leaving yourself exposed to compliance troubles, so correct those errors quickly!  To learn more about ABN requirements and to download the current form and its instructions visit Medicare’s ABN page.

To learn how to protect yourself AND get paid better for what you do from Medicare and ALL other insurance payers, check out our upcoming Chiropractic Progress Seminars where we will teach you proper chiropractic billing, coding, documentation, compliance and – of course, business strategies to help you work smarter, not harder!