• ABN Usage for Dual-Eligible Patients


    Question: We have a patient who qualifies for Qualified Medicare Beneficiary (QMB).  Are we able to use an Advance Beneficiary Notice (ABN) for a lesion removal?

    Answer: Yes. However, there are stipulations on collecting payment. Under option 1, the practice will strike-through language: 

    Option 1: I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.

    Then both Medicare and Medicaid will need to process the claim. Upon determination, the patient may be responsible in one of two circumstances:

    • If the beneficiary has QMB coverage without full Medicaid coverage, the advance beneficiary notice (ABN) could allow the provider to shift financial liability to the beneficiary per Medicare policy.
    • If the beneficiary has full Medicaid coverage and Medicaid denies the claim (or will not pay because the provider does not participate in Medicaid), the ABN could allow the provider to shift financial liability to the beneficiary per Medicare policy, subject to any state laws that limit beneficiary liability.

    For additional information on QMB, see the Academy’s resources.