CMS-R-131 comment #7

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ILLINOIS

JOHN 0. DINGELL, MICHIGAN
CHAIRMAN

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March 8,2007

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TEXAS

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The Honorable Leslie V. Norwalk
Acting Administrator
Centers for Medicare and Medicaid Services
200 Independence Avenue, SW
Washington, D.C.20201

Dear Ms. Nowalk:

I am pleased that your agency is reexamining thc Advanced Beneficiary Notice (ABN)
- with the intent to improve the notice for Medicare beneficiaries and pro,this ABN is used to inform beneficiaries in instances where there is uncertainty surrounding
Medicare's coverage of an item or service. I am pleased that the Centers for M e d i c a r h -------Medicaid Services (CMS) has offered an opportunity for p u b l i c ~ - o n ~ m w
ofthe form design and content may affect a beneficiary's decision about whether to
receive care, it is imperative that the form be clear, concise, and accurate.

I am concerned that, as currently proposed, the revised ABN will be confusing to
beneficiaries and may inadvertently discourage beneficiaries from seeking Medicare coverage of
a needed service. In addition, the revised ABN does not mention the "Ihklpbr determination
process" which beneficiaries can access in ceaain instances. This information is particularly
important as it may encourage beneficiaries to not forgo needed care upon learning initially that a
service or treatment may not be covered by Medicare. I worked with former Representative Greg
Ganslce and the late Representative Charlie Nowood to enact that provision into law.
Attached are more detailedco~matsonthe revised ABN as proposed in the Federal
Register Volume 73 Number 36 on February 23,2007. I appreciate your attention to this matter
and ask that this letter and attachment be made part of the record.

I'

JOHN D.DMGELL
CHAIRMAN

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Attachment to March 8,2007, letter from Rep. John D. Dingell

Typically one Advanced BeneficiaryNotice (ABN) is providedfor each service in
question. The proposed revision of the ABN form, however, appears to p&t as many as
six services to be listed on the notice. Yet the notice does not allow beneficiaries to
demonstrate that they want some, but not all, of the services/careor that they want some
but not all of the sewices/care billed to Medicare. The ABN should be revised so that
only one service is covered by an individual ABN notice.
As mentioned in the cover letter, the ABN does not address the "limited prior
determination process." This process would allow beneficiaries to find out in advance
whether Medicare would cover a service for which the provider was unsure of Medicare
coverage. The ABN should be revised to allow beneficiaries to use the limited prior
determinationprocess.
The ABK should better emphasize the right to appeal if the Medicare claim is denied. The
notice does mention that once, under G.3., however this should also be included earlier
on. After the phrase "We must bill Medicare when you ask us to,"the CMS should add,
"and you can appeal if Medicare declines to pay." The following sentence regarding
billing private insurance should go elsewhere, since it is confusing in this location where
the subject is Medicare billing.
Option 2 undm G states that if you choose 2, "you cannot appeal to Medicare." This is
not completely accurate. Someone can choose 2, and a few months later change her mind,
and ask the provider to bill Medicare. The language should be changed to "I understand
that if a bill is not submitted to Medicare, I have no appeal rights."
Option 3 under G states that the provider can ask for the money upfront even though the
person has requested a demand bill. Depending on the setting in which the ABN is used
this may not be right. The ABN should say "Part B ABN" to clarify that this is not to be
used in the SNF setting where rules are different.
Option 3 under G should be moved up in the order. Since the norm in Medicare is to
receive a service and bill Medicare, the process with which patients are most familiar,
that should be the first item listed, or at a minimum listed before having the.beneficiary
pay 100 percent of the cost of the service and not have Medicare billed.
CMS must ensure the AE3N i s printed in other languages. At the very least, it should be
printed in Spanish.

Too much of the ABN is in bold and underlined, which th& loses its effect. CMS should
minimize the use of bold and underline in the document.