CMS-R-131 Comment #15 thru #16

Al'Ibl&p
American Pediatric Uedicnl Association

93 12 Old Georgetown Road
Bethesda, Maryland 20814-1621
Tel: 301.581.9200
Fax: 301.530.2752
www.apma.org

Apriil 9, 2007
Centers for Medicare & Medicaid Services
Offi~zeof Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Atte.ntion: Bonnie L. Harkless
Rooim C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1 850
Dear Ms. Harkless:
The .American Podiatric Medical Association (APMA), the national organization representing
more: than 11,500 of America's Foot and Ankle Physicians and Surgeons, is pleased to offer
comments on recent changes to the Advance Beneficiary Notice of Noncoverage (ABN).
We support the decision to combine the previous two versions of the ABN, form CMS-R-13 1-G
and CMS-R-131-1, and believe that one form is better for both beneficiaries and physicians,
provi~ders,practitioiiers and suppliers. We believe that use of a single form will eliminate some
of the confusion that occurred previously when a beneficiary was presented with different
versions of the ARN.
We believe that it would be useful if the form listed the possible reasons for denial so that the
physician could simply check the appropriate item. We recommend revising the form to include
the b i ~ i creasons why a service would be denied, such as Medicare will not pay for the service or
item, or the service or item has not been proven effective, or there are limits on the number of
services or items allowed by Medicare. An "other" section could be included but by pre-printing
the more common reasons for denial on the form, the beneficiary would generally encounter the
same language regarding denials. This would also eliminate the burden on the physician or
office: staff to recall and write out Medicare's reasons for denial.
Additionally, we are concerned that the revised form may be confusing to beneficiaries and may
lead t'o misunderstandings regarding who is responsible for payment of an item or service. The
first paragraph in the ABN states "it is likely you or other insurance will have to pay." In the
overwhelming majority of cases, a patient's other insurance acts as a co-insurance to Medicare
and does not pay if Medicare does not pay. The language in the new form could lead a
beneficiary to assume that someone else will pay for the item or service when, in fact, most of
the tirne the beneficiary will be responsible for payment.
The p:reviousversion of the ABN (CMS-R-13 1-G) specifically said "we expect Medicare will
not pa.yVwhile the new one states "we think Medicare will not pay." The APMA believes that
the or:iginal language was more definitive and better communicated to the patient that Medicare
would not pay for an item or service. The revised language, which is softer, could result in more
misunderstandings between patients and physicians. If a patient believes Medicare might pay,

American Podiatric
M e d i c a l A ~ s s o c i a t i o n ,I n c .

Ms. :Harkless
April 9,2007
Page 2

they may be more willing to agree to a service or item. If they discover subsequently that
Medicare did not pay and they are now responsible for payment, they may argue that the form
they signed led them to believe that Medicare would pay. Since the physician provided the form
initia.lly, the patient may unfairly assign responsibility for Medicare's decision to the physician.
The new ABN states, "You still can receive this care, since you or your health care provider may
have good reason to think you need it.. ." while the old version stated, "The fact that Medicare
may not pay for a particular item or service does not mean that you should not receive it." We
believe that the previous language was more respectful of the physician and his or her decision
making and encourage CMS to return to the original language.
While the APMA recognizes that the addition of the telephone number is helpful for the
beneiiciary, we do not believe it is practical to expect that the physician will have time to wait
while: the beneficiary contacts Medicare in the office setting.
Also, by bolding and underlining the statement, "I can appeal that decision," there is an
implication that the patient has a reasonable chance of getting paid by Medicare eventually. The
previlous version of the form mentioned the possibility of appealing but did not bold the
infonnation. We support retaining the sentence but suggest that it does not need to appear in
bold ]print.
Item :H of the revised ABN is for "Other insurance to consider for billing." As part of the normal
course of business, a doctor's office will obtain insurance information from the patient so it is
not necessary to request it on this form. By including the request on the ABN, the patient may
again be given the impression that some other entity will pay the claim and the patient will not be
respo:nsible. We think this could lead a beneficiary to agree to a service or item that they would
not otherwise agree to if they fully understood they would likely be responsible for payment.
We a]>preciatethe opportunity to offer these comments. If you have questions regarding our
respoinse, please contact Dr. Nancy L. Parsley, at (301) 581-9233.
Sincerely,

Christian A. Robertozzi, DPM
Presidlent

IOWAHEALTH

PHYSICIANS
AND CLINICS

' April 6,2007

Centers for Medicare and Medicaid Services
Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development - C
Attention: Bonnie L. Harkless
Room C4-26-05
7500 Security Boulevard
Baltimore, MD 2 1244- 1850
RE: Comments on Proposed Revisions on Advanced Beneficiary Notice Form and Use
Dear Ms. Harkless:
I appreciate the opportunity to comment on the revisions to the Advanced Beneficiary
Notice (ABN) form and instructions for use outlined in the February 23,2007 Federal
Register (8 167). I am the compliance director for a multi-specialty practice comprised of
240 providers serving patients at 65 clinic locations in Iowa and western Illinois. Many
. of our physicians and non-physician practitioners order for patients services with
applicable local or national coverage determinations which could limit coverage; our
clinics issue ABNs to patients for these services.

I have comments in four general areas. First, the instructions are helpful; however,
please add further clarification on identity of the "notifier." The instructions indicate
that this form is to be completed, delivered to the patient, and retained by the "notifier."
In situations when the entity that actually performs and bills for the test (e.g., reference
laboratory) has no contact with the patient, who is the "notifier?" In cases when the
service is furnished by an entity that is not affiliated with the ordering provider, is the
ordering provider ever the "notifier"?
Second, the form should emphasize that the "estimated cost" is just an estimate and
actual cost to the beneficiary may vary. For example, the clinic may draw the specimen
and send it to the reference lab with orders for a particular lab test that may be denied. If,
in this case, the notifier is the clinic that drew the specimen and ordered the test, it may
be difficult for the clinic to know with any amount of certainty what the estimated cost
will be, especially since the lab submitting the claim will be able to bill the charge (rather
than the allowable) if the claim is denied.
Third, since the three reasons for possible denial are defined by Medicare, they should be
pre-printed on the form for more efficient completion by the notifier. Print the reasons,
each preceded by a checkbox, in the Blank E or assign each a letter (e.g., A = "Medicare
does not pay for these tests for your condition", B = "Medicare does not pay for these
tests as often as this ...", etc.) and allow the notifier to indicate by letter the reason for

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denial in Blank E. I appreciate the clear statement that this form can be used to advise
patients about services that are always non-covered and for which the beneficiary will
have full financial liability. This being the case, I suggest that an additional reason for
,possible denial be added for Blank E: "This service is considered noncovered by
Medicare."
Similarly, the form could be completed more efficiently if we were permitted to prepopulate the form in Blank D with certain high volume services which are frequently
non-covered.
Fourth, I would like to see further clarification in the instructions in several other areas:
" Clarify under what circumstances a single ABN can be obtained for a series of
services that may be non-covered (e.g., monthly B12 injections).
" Include specific guidance on the procedure for handling beneficiaries who have been
given the notice and who wish to receive the service but refuse to sign the ABN. I do
not believe that the proposed changes will fully eliminate this situation.
" Clarify who can serve as a patient's representative.
In general, this form is simpler and an improvement over the past versions.

Erika ~ i b d e nCHC
,
Director of Coding and Compliance

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