Advanced Beneficiary Notice (ABN) Use Expanding
Medicare does not pay for services (exams, tests, procedures, etc.) unless medical necessity exists and is documented in the patient record. In many cases, additional conditions for coverage are based on testing frequency. If Medicare may not cover a test or service, but the physician or APP believes it is still appropriate, an Advanced Beneficiary Notice (ABN) must be provided to the patient in advance, informing them of the potential for non-coverage by Medicare. Recent audits have identified that Corewell Health and ordering physicians and APPs may not be meeting Medicare requirements for ABNs.
To ensure we fully meet Medicare requirements, on Tuesday, July 18, 2023, Corewell Health will turn on additional ABN features in Epic for several tests, exams and procedures. These additional notices will “flag” medical necessity as well as frequency of orders. In line with our current policies and as required by Medicare rules, Corewell Health and ordering physicians and APPs (including employed physicians and APPs and independent physician offices that utilize the Community Connect platform) are responsible for collecting patient signatures on ABNs or informing patients of the need to complete an ABN at the time of test collection. Ordering physicians and APPs are also responsible for ensuring the medical record reflects medical necessity for testing.
What will change for ordering physicians and APPs on July 18?
ABNs are not new, but they will now be required for many more tests and procedures. When you order a test or procedure, such as a lipid panel, A1C, vitamin D assay, mammogram, colonoscopy, or thyroid test, if the patient record indicates that the patient does not meet medical necessity criteria or the test has a frequency Medicare coverage rule, you or someone on the team will be prompted to print and have the patient sign the ABN at the time of collection or performance of test.
Gathering ABNs for our Medicare patients is not optional. The ABN functionality in Epic will help both you and Corewell Health comply with Medicare rules and conditions of participation. It will also help ensure that patients are fully informed of their benefits and coverage, at the point of service.
Although an ABN is intended to ensure patients are aware of the potential non-coverage and cost to themselves, it does not absolve an ordering physician or APP from the responsibility to ensure the test is both medically necessary with appropriate documentation and is not being performed at a prohibited frequency.
Where does this change apply?
The additional ABN features in Epic will be new for the East and South regions. These features are already active in the West region.
You can learn more about ABN requirements here:
If you have questions, please contact Sarah Britton, VP, Laboratory Services.