By Audrey Landers
One of the most important parts of what we do at SCG Health is client education. We are always eager to answer questions and help our clients navigate the sometimes murky waters of the medical industry. Recently, we received this interesting question:
“We are participating in Medicare and submit claims with the GA modifier for non-covered charges would fall under the “frequency limits.” Do we have to accept Medicare allowance, or can we bill the member our full charge for a non-covered service if an Advanced Benefit Notice is signed? “
There are a few different components to this question, so let’s break them down.
Depending on the case an Advanced Benefit Notice (ABN) may not be necessary. ABNs only apply to services that could be covered by Medicare, but the provider has reason to believe the claim may be denied. For example: the Centers for Medicare and Medicaid Services (CMS) may deny a claim for a service that is not medically necessary. In this case however, frequency limits draw a clear boundary set by Congress for what is and isn’t covered. You are not required to submit the claim to Medicare because it is an excluded service. You could use a (now retired) Notice of Exclusion from Medicare Benefits (NEMB).
The difference between these forms is small but significant:
- ABN- Informs the patient that Medicare may or may not pay for the service they receive, and if Medicare does not pay then the patient will be responsible.
- NEMB- Informs the patient that Medicare will not pay for the requested service, and the responsibility of payment will fall on the patient.
On both these forms, you will write in an estimated cost for the patient to review. Whatever you write in this section is the appropriate amount to charge. The key is that the patient is given advanced notice of what to expect.
We think the real question here is “what amount should we use as the estimated cost on either an NEMB or ABN?”
The answer is that you should use the self-pay rate (not the actual and usual charge) for any service that Medicare will not charge. You should treat them as any other patient who is paying for a service completely out-of-pocket. Of course, we are assuming here that your self-pay rate is higher than the Medicare allowable.
We take great pride in being helpful and informative, if you have any questions, you can ask us or click the “Gina, Help Me!” tab at the top of our website.
We hope you will take the time to learn more about our educational services and view our events calendar. SCG Health typically holds one free webinar each week, so be sure to check the calendar for events you are interested in.