The ABCs of ABNs: Insights from Healthcare Compliance Pro Keisha Wilson

Are you navigating the complex world of healthcare compliance, particularly when it comes to Medicare and Advanced Beneficiary Notices (ABNs)? We've got you covered in the latest episode of Compliance Conversations, featuring industry expert Keisha Wilson, founder of KW Advanced Consulting. 

Keisha brings over two decades of healthcare experience to the table, offering invaluable insights into the intricacies of ABNs. This episode delves deep into what ABNs mean for healthcare professionals and patients alike, recent changes to ABN forms, compliance risks, and the importance of proper education and implementation within healthcare settings. 

Why Tune In? 

• Uncover the essentials of ABNs: Learn what ABNs are and why they're critical in healthcare from a seasoned expert. 
• Stay updated: Get the scoop on the latest ABN form changes effective from June 2023 and how they impact practices. 
• Avoid common pitfalls: Keisha discusses frequent compliance risks and how to navigate them effectively. 
• Engage in comprehensive learning: From policy implementation to case studies, this episode is packed with actionable advice and best practices. 

Keisha's journey from aspiring social worker to healthcare compliance consultant adds a unique perspective to understanding patient communication and the nuances of Medicare coverage. Her passion for compliance and patient care shines throughout the conversation, making it a must-listen for anyone in the healthcare sector. 

You can also read a recent blog post from KW Consulting on ABNs. 

Keisha Wilson, CCS, CPC, CPCO, CPMA, CRC, CPB, Approved Instructor, is the Founder/CEO of KW Advanced Consulting LLC, Minority Women Own Business Enterprise (M/WBE) Certified, with 20+ years in healthcare specializing in various areas of compliance. Multi-specialty, Telehealth/Telemedicine, Risk Adjustment, provider and coder training. She currently sits on a Board of Directors for an outpatient mental health clinic. Keisha is a licensed PMCC who teaches coders looking to become Certified Risk Adjustment (CRC) and hosts various compliance documentation and coding webinars. She is a published author, having written for AAPC editors on Primary Care Coding Alert, Healthcare Business Monthly, and KW Advanced Consulting coding articles. Keisha can speak at various events this year, including the AAPC Regional Conference on Philidelphia and Cohen's Coding Summit on Telehealth in the U.S. vs Internationally. 

Episode Transcript

CJ: Hello everybody. Welcome to another episode of Compliance Conversations. My name is CJ Wolf with Healthicity and today's guest is Keisha Wilson. Welcome to the podcast, Keisha!  

Keisha: Thank you so much, CJ! It's a pleasure to be here.  

CJ: We're so grateful that you’ve taken some time to talk to us. We're going to be talking about Advanced Beneficiary Notices or ABNs. But before we get to our topic, Keisha, we always enjoy hearing from guests a little bit about, you know, maybe their professional path a little bit or how they ended up where they are, or whatever you're comfortable sharing. I would like to know a little bit more about what you're doing professionally.  

Keisha: Yeah, sure. So, of course, as CJ mentioned, my name is Keisha Wilson, so I'm the founder of KW advanced consultant. I've been independent right now for about two years, but I've worked in healthcare for over 20 plus years, and held various positions from front desk, billing auditor, compliance manager, interim director. So, there's a lot of experience in the healthcare which gives me those skills and or soft skills to speak to physicians and coders because I've kind of experienced all aspects of healthcare. And funny enough, I was going to school to be a social worker and I got into the Master’s program and then I decided to go into coding instead. So, it's always funny when people hear me speak, they say I have this type of understanding or this soft tone and that's because initially I was supposed to be a social worker and I left that.  

CJ: Very good. No, very good. I totally get it. You know, I came from a clinical background initially and having gone to medical school and then I ended up doing this for 25 years and it's like, how did you end up there? So, that's why I like asking that question at the beginning just to because we all kind of come from different backgrounds but we all kind of then find our niche here and it sounds like you have a lot of great experience at different roles in healthcare, so you understand probably that full cycle; revenue cycle and coding cycle and reimbursement cycle. So, thank you for sharing that.  

Keisha: You're welcome!  

CJ: Well, Keisha, let's talk about Advanced Beneficiary Notices or ABNs. So, we'll refer to them as ABNs throughout the podcast, but let's just level set everybody because, you know, we have people who have coding and reimbursement background listening, but we also have you know compliance professionals who may be compliance leaders and they might not have in depth detailed knowledge of some of these terms. So, can you just tell us what ABNs are?  

Keisha: Of course! So, ABNs or as CJ mentioned, they're called Advanced Beneficiary Notice of non-coverage. And so, this is a form that healthcare professional would give a Medicare patient and it's fee for service, so it doesn't apply to those that have the Medicare Advantage plan or Part C or Part D prescription coverage, but just the fee for service. And this is the physician or the provider or the supplier letting them know that Medicare may not cover this service and for various reasons; it may not be medically necessary, maybe you exhausted all the limits, maybe they feel you're doing better, but you decide you want to go ahead and still see the provider and get those services. So, they're letting you know that you may be liable, Medicare may not pay, and if anything, now the financial responsibility will be on the patient.  

So, the form, this is one beautiful pager and it's very detailed where you have to fill out this information and we'll get into more of the compliance risks when it comes to those forms, but the forms are very important and it's often produced in the outpatient setting, but there's various forms that there's some for the inpatient setting, skilled nursing facilities have theirs as well, laboratories as well as pharmacies may also give you. So, there're various versions, but we're going to talk about ABNs for the rest of the podcast.  

CJ: Yeah, exactly. And you know, they've been around for a long time, but the name is very descriptive; Advanced Beneficiary Notice of non-coverage like you said, you're giving it to them in advance so they can make an informed decision. And like you said, we'll get to some of the specifics here in a moment, but you have to describe why and things like that.  

Just to kind of set the stage a little bit, it can be a tough conversation because if a doctor or whoever is completing the form with the patient says; "Medicare might not think this is medically necessary," "Well Doctor, then why do you think it's medically necessary?" So, it's always can be an awkward conversation because we have to keep in mind that doctors are free to order and practice the way that they feel is appropriate based off of their medical license and Medicare would be quick to say; "We're not telling you doctor how to practice. What we are saying is what we will cover and reimburse and what we will not cover and reimburse." And so, you can get now kind of these differing opinions of what Medicare thinks should be covered versus what the doctor thinks what should be covered and it can be kind of, sometimes they're can be awkward conversations because it involves money.  

Keisha: Exactly! And it's always important and it goes back to documentation. What does documentation state, are you showing in the record that this is medically necessary for the patient? Oftentimes documentation may be lacking or they're not explaining to the patients clearly that this is really a service that is needed regard we assessed your condition and we really feel that this would be helpful or of value, you know to your company that it's done.  

CJ: Yeah! And if Medicare denies, then we could ask you to pay and we will ask you to pay. So, I've been involved, you know, with coding and billing a long time, but I haven't been super in the weeds on ABNs. Have there been any recent changes or changes in general that you're aware of?  

Keisha: Yes. So actually, last year. There was new ABNs forms, so CMS approved it as of April and then effective June 30th of 2023. They were mandatory, so if you were using old forms like during COVID, they extended the date so it allowed practitioners to continue to use the older form. But we knew with the PHE coming to the end that there was going to be a new ABN form anyway. So as of June 30th, of 2023 there's a new ABN form that you must use going forward and that's good until January 31st of 2026.  

So, it's always important that they're using the most current and up to date form that's going to segue into the non-compliant area, but sometimes they're using older forms and if you're using older forms then it's like you never fill that one anyway.  

CJ: Yeah, right? Like it's kind of funny. Like have lawyer friends that, you know, talk about how a contract and some things can be a legal document on a napkin and because you've elucidated or you've clarified certain elements of maybe a contract or an agreement or whatever. That's not the case with ABNs, it has to be on their form and the current form, right?  

Keisha: Exactly! And they're so particular, you know, they give great instructions, CMS, if you go on their website, it comes in English and in Spanish they also come with instructions on how to properly fill out the form. Where you should look on the form, the lower left-hand corner to make sure that it's the current CMS R-131 form and the expiration date. That's one thing that a lot of people don't really look at is the expiration date and they may, you know, pull out old form from their system and that form had expired years ago.  

CJ: Exactly! And so, we're kind of segueing now into some of those compliance risks. One you just mentioned; using the wrong form. What other compliance risks have you encountered maybe during past or recent audits relating to ABNs?  

Keisha: So, with compliance, unfortunately we find a lot of risks when it comes to ABN forms believe it or not. So, one as we mentioned is using outdated or expired forms. The next one is not completing the form in its entirety. You're supposed to pull out every section of the ABN form. You know the MLN has instructions, the manual has instructions, CMS has it. MACs, actually the Medicare Administrative Contractors they actually have a lot of detail, even videos on the website telling you how to fill out the form.  

Next one is signatures. Oftentimes, providers may give a patient the form, the patient doesn't sign it, or if the patients unable to sign you are able to have a representative of your family or legal guardian sign that form, the signature is missing, the date is missing.  

And then the options. There's three options on the form; option one, option two, option three, and often time one of the options are not checked. So, if it's not filled out, these are often times risk areas.  

And then there's also the area where you're supposed to put in detail the service that Medicare is not going to cover as well as how much is this going to be the duration is missing. So, there's a lot some people feel like; "OK, I can just skip around boxes," but if you skip around, boxing means the form is not completed in its entirety, and so oftentimes that that's the biggest risk that we see.  

And then the most, I think the biggest one is sometimes they provide services and then they give them the phone after. If you give them after then it still doesn't count because you were supposed to give it to them way in advance that they were able to make an informed decision, they understand what it means that this form should be filled out, that they're now going to be liable for any financial obligation if CMS doesn't pay for it, and so you don't want to rush them. So, I would say those are definitely some risks that we see when it comes to ABN and compliance. Oh, and I actually just had one more thought.  

CJ: Yeah, please.  

Keisha: Some offices don't even know what an ABN is.  

CJ:  I know!  

Keisha: So, I think that's like the biggest risk. If you're providing services to Medicare patients, your staff should know what a ABN form is. And if they're not comfortable in speaking to it, they should just be at least one person designated in the office, even if it's not the physician that understands the form and is able to explain it to the patients in clear language.  

CJ: Exactly! And you know Keisha, I'm curious what your thoughts are on this as you work with clients, we always had a policy, right? So, and the policy would clearly closely mirror kind of the CMS guidelines on how to fill it out. So, you know we internally we said; "Look guys, these are the expectations if we don't follow our own policy, we're not going to be able to bill a patient for this. We will then be accountable for the financial burden and we have to write that off if Medicare is not going to cover." Do you see policies as an important part of this process?  

Keisha: Definitely! And with anything with compliance and auditing, you know, once you find a risk, there should always be some type of policy or procedure that's set-in place after and with ABNs, that's one that's continue, it's like a work in progress. I think some organizations or physician practice may not really understand the implications of not having these forms filled out properly sometimes until you feel it in their pocket. But I always like to explain to them like; "Imagine if you were the patient and you're going for these services and you needed it, but you didn't realize your insurance company may not pay for it, and now you're liable for it. But you didn't really understand all of this you know, so you kind of have to turn it around and pretending you were the patient, how would you feel if this wasn't explained? You know, I want to know." So sometimes when I go to doctor's office, I don't tell them who I am. I don't tell them what I do. I just try to see how are they with communicating certain situation and if I need to have certain procedures; is it explained to me.  

CJ: Yeah, I'm the same way. And when I go with loved ones who are Medicare beneficiaries, I've even helped loved ones, you know, they get a bill from the doctor's office and then it explains Medicare didn't cover this and you signed an ABN, I'm like; "OK, I want a copy of that on your behalf, loved one. I'm going to review it," and if it's like you said, an outdated form. If it's not completed accurately, I respond to the medical practice and say; "Sorry, this is an invalid, ABN you're going to have to pay for it. Not my loved one." 

Keisha: Exactly! And funny enough, you said that I did attend an appointment recently with one of the family members who has Medicare fee for service and they were explaining services. And they were talking about financial responsibility. And I'm like, "OK, well, where's the ABN?" And they're like; "Oh, yes, let's go get it." So, these are all things to keep in mind. I think patients are a lot more aware now than they were before of their rights and certain things. And so, it's always important to give them that benefit of the doubt and you know, just explain exactly. They just want to know what's going on with them and what they'll be responsible for and what their insurance will cover.  

CJ: Yeah, it's kind of common courtesy stuff, right? It's like, what would you like? You like you said, what if you were a patient, how would you like to be treated? The other thing, Keisha, I'm curious if you see this very often but, and if this is still the case, but I understood that you also cannot give an ABN under duress, meaning like the patient you can't have prepped the patient, let's say it's an injection and joint injection in the spine or some and there's, you know, Medicare limitation on the number of times you're allowed to have those injections. You can't prep the patient, have them on the table ready for the injection and then say; "Oh, by the way, we need to have you sign this ABN in case Medicare doesn't pay." Is that still the case?  

Keisha: That is still the case, and the rest in case of emergencies, they should not be given them because they need to be able to think clearly, to make an informed decision. Oftentimes in case of emergency and stuff like that, patients are in pain, there's different circumstances, so they're not thinking clearly about financial obligations, so it wouldn't be right to shove a paper in their face to say; "Hey, you're going to be responsible for this in case they don't cover it."  

CJ: Or we're not going to do the service, right?  

Keisha: Exactly, right! In that case, you have to understand that this may be a responsibility for the organization or the physician depending on if the payer pays or not. But the patient's health is priority and most important.  

CJ: Yeah, this is fascinating. We're going to take a quick break and we're going to come back and talk some more about ABNs with Keisha in one moment.  

Welcome back everybody from the break. We're speaking with Keisha Wilson, who is informing us about so many important aspects of the Advanced Beneficiary Notice of non-coverage or ABNs Keisha to kind of continue on with this conversation when should or shouldn't a provider use an ABN like, are there business reasons? Just in general, how do you consult with clients?  

Keisha: I always say that it's best for them if they're not sure if your staff is not sure what services are covered, you want to take a look at your LCD so your Local Coverage Determinations or your NCDs to see what CPT diagnosis codes HCPCS codes are covered. Oftentimes you'll know, and it will give you the information go over medical necessity. You also kind of know which services there's some preventive services that are just not always covered. Seamless has a great list that says if some services are experimental, they're not covered; cosmetics. So, it's always best to check to see what is covered. If it's the physical therapy, is there limitations on certain services and now this patient has exhausted all?  

There are three instances where they kind of give when it comes to ABN, so initial reduction and termination, right? Initial services, patients coming in for new services. You check the LCD, NCD you know this is a non-covered service, but whatever is going on with the patient, you feel like they would benefit from this procedure. Then you would have them fill out this ABN.  

Then there's a reduction when there's a reduction of services, they probably meet their frequency and limitations but the patient still feels like they want to go ahead and have these services, you would have them fill out this form.  

Then termination this patient has reached maximum medical, they're better; improvement, right? For example, and in this case the patient still feels like they still want to go ahead and have more services. They feel themselves like; "I'm not 100% better, even though you think I'm I've reached improvement and I want to go ahead and do it."  

CJ: Right! 

Keisha: So, these are kind of services, but then there's also times when we know that Medicare never pays for these services whatsoever. In most cases, they always say you can give a patient a voluntary ABN and so with the voluntary ABNs that's a little different where you may not, they don't have to check a box, they may not have to sign and date it. But you're just letting them know that Medicare is definitely not going to pay this, that you're going to be responsible. But I'm just giving you this voluntary one. So, there's different situations when it comes to ABNs.  

CJ: Yeah, like in that last scenario, you're kind of giving it to them as a courtesy, right? Like; "Hey, patient you it sounds like you might not, in a respectful way you're not, you don't know everything that your insurance covers." You know, this is really on you as a patient to know that Medicare never covers ex ever. And so technically I don't have to give you an ABN. I'm just doing it to let you know that you will be responsible for this, just as kind of a good business practice, but if you did not do an ABN in that scenario, you could still bill the patient because it's a service that's never covered, right?  

Keisha: Exactly! And we know it's never covered and so they should be, and usually they're aware of it, but it's almost that as you mentioned common courtesy just to let them know and even when filling out the ABN form you know as I mentioned before, there's three options.  

There's one where the patient is aware that this may not be covered. But there's appeal rights when it comes to option one. Also, if a patient has dual insurance, some may have Medicare, Medicaid and other secondary payers. And so oftentimes you're billing Medicare first and depending on if they deny it, then you're going to submit it to Medicaid. But again, you want to be careful, because when it comes to state laws with Medicaid, sometimes you're unable to bill patients for any financial obligations, so you want to review those.  

And then the second option is to have the patient select that one. They know they're going to be liable 100% for the services. You're not billing Medicare at all, so you're just having them fill out, you know, pay for the services, they check option two.  

And then the third option is they don't want these services. You've explained to them, they realize maybe they can't afford it. Maybe they decide they want to go for a second or third opinion and they don't want to do it right now. And so, they're aware of all the options that they have.  

CJ: Yeah, exactly! Now you kind of mentioned the PHE and COVID and stuff and we did a lot of things remote. What if a patient client Cannot sign an ABN in person, are there steps that have to be done?  

Keisha: Yes, a good question. During the public health emergency, so much things have happened and we went fully remote on most places. So, if a patient is unable to sign an ABN in person, there are options where you can get on the phone and do it audio only if you want to have a telehealth, or virtual audio-visual communication with them. You can also e-mail them the document, but you need to explain. So, you still need to give that common courtesy and explain exactly as you would if the patient was in person. They understand their responsibility, how much things are going to cost, which option. And then they are able to sign it electronically, or you can mail them a copy and have them sign it. The provider wants to keep the original copy, but you always want to provide the patient with a copy as soon as possible, so you're sending will via e-mail or mail right after they sign it.  

And they can also decide over the phone; "You know what I don't want, and maybe I checked option one, but I don't want to do it anymore!" And if they decide that they don't want to have the service anymore, then it's like an addendum that you have to do to the ABN and check the new option, why they don't want to have it, a new data service and a new signature as well. And then you want to get them that copy as well, and you want to retain a copy for yourself.  

CJ: Gotcha! One thing and correct me if I'm wrong. So, let's say you do everything right as a physician office, for example, or a patient type of setting. You do it all correctly. You administer the ABN correctly. You know you're going to go through the claims process. Are you supposed to still put on a certain modifier saying that there's a valid ABN on file when you submit claims is that a requirement?  

Keisha: Yes, so good question. So, there are quite a few modifiers when it comes to ABNs. There's GA, GX, GY, GD, GK, and GL. There's also another one, KX, a recent one, that one, you have to watch documentation because you if you don't, you may not need a patient to fill out an ABN if you feel like whatever is going on with the patients, condition and medically necessary documentation supports you're submitting information to CMS, and oftentimes they may end up paying or you may have to appeal and they'll pay. So, the KX modifier is just saying that documentation supports that this is a needed service.  

Then there's the ABN one so for example there's the GA modifier which they would append to show that. They will report when you issue a mandatory ABN for a service as required and keep it on file. So oftentimes they don't need to submit a copy of the ABN, but you must make it available upon request in case CMS asks for it. And then there's also ones that they would use if there was no ABN on file. They would attach like the GX modifier along with the GY. So, they really want to review like the guidelines to make sure they're appending the most appropriate modifier when it comes to ABNs as well.  

CJ: Yeah, I thought that that was an important thing. Let's say we have providers listening or we have compliance and coding billing auditors that are listening and they work for providers and they ask the question; "Well, how do I know if something's covered or not?" Like, what do you tell clients and others where they can go to find out if services are covered?  

Keisha: I always mentioned as I did before, that they always want to check their LCDs and NCDs in case there's not a local LCD. You know, the national one trumps the local LCD, so you want to check both. You also want to check your MACs to see what information they have regarding the cover services as well. I always refer them to at least those three, because those should guide you with the services and diagnosis codes, CPT codes, HCPCS codes so you know if the services are covered under Medicare.  

CJ: Yeah, I always when I was educating and I'm curious if you still think this philosophy would work today. I would tell people, "OK, if the service is sometimes covered, but you've also known that sometimes it's not. You're kind of in the ballpark of ABN talk, right?" like we should probably thinking of an ABN. If it's never covered and I think correct me if I'm wrong, you could also have a pay a physician or somebody go to the Medicare physician fee schedule database because there's certain status codes that will tell you if it's never covered and if it's never covered, that kind of puts you into that ballpark of; "OK, if we say an ABN, it's more of a courtesy to let them know. But you know, technically we don't have to have it in order to build them." Is that kind of thinking still accurate today?  

Keisha: Yes, a 100% and that's I forgot to mention the fee schedule, but that's another way I also mentioned to them when I educate about that, I think sometimes they just don't know, but there's always ways to find out what services are covered. Usually new services that haven't been approved, you know, hasn't gone through the process, you know, it's experimental or investigational, they're not going to cover it whatsoever as we mentioned. You know, you may not necessarily need to give an ABN, but as you mentioned it could be a voluntary one that they're just aware that they may be liable for these services.  

CJ: Yeah! 

Keisha: And then there's other times when it comes to physical therapy or other services where they just maybe maxed out the service or maybe it's a screening service and they're before that age that it's allowed, you know, but for whatever the documentation of family history, there's a need for this screening and preventive service so they may provide the ABN.  

CJ: Those are all such good points and Keisha, we're kind of coming to the end here. I'll ask you in a moment if you have any last-minute thoughts, but I love what you said about kind of the LCDs and NCDs because those are those are like conditional coverage, right? It's like, yeah, Medicare covers the CT scan of the head, but not for a stubbed toe, right? Like there's diagnosis codes for when that are approved, that when we will cover it, but there are times when we will not cover it, so those might be good times to think about ABNs and have a process in place.  

I remember, I worked in one organization where cancer services was a big issue and certain drugs are very, very expensive, especially when they're in and I won't use the term experimental because Medicare has certain coverage guidelines for certain cancer services. But anyway, we were being denied, you know, thousands and thousands of dollars for these drugs. But the patients really wanted them and in order for us to be able to bill the patients, we had to kind of set up a process that that was that clarified. So, I really appreciate your comments about LCDs and NCDs. Any last-minute thoughts before we before we close or any closing thoughts?  

Keisha: Oh yes, and I have, well, a few. But what you just mentioned about the cancer one that was the example I gave with the family member that I went; it was actually one of those type of scenarios where it was hematology oncology and it was that type of service that was being produced, you know, explained, and to see if they would want to go ahead. So, I'm glad that you mentioned that cause that's often times you may see it sometimes urology, OBGYN, sometimes there's certain services that you may just always see ABNs more than others.  

And lastly, I would say education oftentimes they don't know what ABN is so getting them used to the form what it is, know where to go. Knowing what information to find LCDs and NCDs, people are not aware of those either that those are out there.  

CJ: Exactly! 

Keisha: And you're like how can you're surviving in 2024 if you didn't know that there's LCDs and NCDs. 

CJ: It sounds like that they need a compliance audit, potentially.  

Keisha: Exactly! My bells always go off when I hear things like that. I'm like, "OK, we need to talk!" So, there's always room for education. You want to educate your staff. You want to make sure that they understand how to explain to the patients to communicate it, that they're not rushing, that they're giving them advance notice that they're able to go over these forms and make an informed decision. You're not pressuring them to sign it, you're not having them pay for anything beforehand before they even aware, that was one thing I forgot to mention that if you do have them pay for it and Medicare does cover it or pay some part, you are responsible to refund the patient that amount in a certain amount of time, whether it's 15 or 30 days. Education is always the best that never stops here. So, I think getting your office or organization on board with ABNs that will help when it comes to revenue as well to make sure that physicians are not losing and then patients are not losing or liable as well.  

CJ: Yeah, wonderful comments to kind of end our podcast today. We could probably talk even more about it, but we are out of time. Keisha, thank you again so much for being willing to share your time and your expertise in this area.  

Keisha: Oh, my pleasure. Thank you for having me on! I truly enjoy it talking about ABN on anything compliance always makes me smile.  

CJ: And that makes us wonder why are we so sick that we like those kinds of things, right?  

Keisha: Yes!  

CJ: I'm with you there. I like it too, but it's like no one else seems to like it.  

Keisha: Exactly! But I love it.  

CJ: Yeah! We can tell that you do and we'll include some contact information for Keisha, if you want to reach out to her or her company. And thank you all for listening. We appreciate your support. Please share with friends if you like this topic and if you have ideas for other topics. If you have speakers in mind that you think we should reach out to that you think might be good guests, please share that with us. And until next time, we hope you all take care. Thanks for listening!