ABN Abuse: A Common Chiropractic Practice?


Recently, during the course of my Documentation Reviews that I perform for my consulting clients, I came across something that was a bit suspicious. From the Medicare charts I reviewed, I noticed incomplete Advanced Beneficiary Notices (ABNs) in each of the files. Despite the fact that the provider’s necessary info was left blank, they had been signed by each of the patients.

To confirm my suspicions, I had the doctor’s staff start randomly pulling additional patient files to see if there truly was a problem. Even if all of the rest of the charts had ABNs in them that were properly completed, the ones I discovered still represented a problem. Unfortunately, the random sampling revealed that all of the Medicare files had ABNs and the vast majority of them were blank (but had a patient signature).

I wish I could say that this experience was a rare moment out of the hundreds of reviews I have performed, but it was not. What may surprise you was that this particular incident involved a Medical Doctor, not a chiropractor! 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.

ABN Background

Before we discuss the specifics of the much abused ABN form, let’s discuss a little background. The release of the mandatory use of the revised ABN form went into effect on March 1, 2009. The new form clearly communicates the purpose of the form to Medicare beneficiaries: it is an “Advance Beneficiary Notice of Noncoverage.” 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, I will address 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.  As the doctor, 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.  One of these 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.

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 postpayment 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.

To learn more about ABN requirements and to download the new form and its instructions visit Medicare’s ABN page.

For more information about my consulting programs which teach chiropractors how to maximize reimbursements and minimize their exposure to audits, feel free to contact me via email – tom(at)strategicdc.com.

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