A properly executed and signed Medicare advance beneficiary notice (ABN) that used the term PSA in place of prostate-specific antigen was deemed invalid in an appeal by a hospital laboratory after the patient received a bill from the hospital and won an appeal from his Medicare Administrative Contractor (MAC). As noted in an article published May 1 by AISHealth.com, Olympic Medical Center in Port Angeles, Wash., appealed the ruling by the MAC to Maximus, a qualified independent contractor (QIC), armed with the signed ABN, but lost the appeal. QIC Used Incorrect Information in Its Decision Maximus used information found in section 50.15.4 concerning the use of abbreviations on an ABN by a home health agencies (HHA) when it said “abbreviations were used without explanation” in its denial letter to the hospital. According to the Medicare claims processing manual, Chapter 30, section 50.3, “Information specific to HHA use of the ABN has been added in §50.15.4. The guidelines for ABN use published in this section and the ABN form instructions apply to HHAs unless noted otherwise.” Maximus also ignored the sample lab ABN provided by CMS, which includes the term “PSA Screen G0103” as one of the tests listed on the […]
A properly executed and signed Medicare advance beneficiary notice (ABN) that used the term PSA in place of prostate-specific antigen was deemed invalid in an appeal by a hospital laboratory after the patient received a bill from the hospital and won an appeal from his Medicare Administrative Contractor (MAC).
As noted in an article published May 1 by AISHealth.com, Olympic Medical Center in Port Angeles, Wash., appealed the ruling by the MAC to Maximus, a qualified independent contractor (QIC), armed with the signed ABN, but lost the appeal.
QIC Used Incorrect Information in Its Decision
Maximus used information found in section 50.15.4 concerning the use of abbreviations on an ABN by a home health agencies (HHA) when it said “abbreviations were used without explanation” in its denial letter to the hospital. According to the Medicare claims processing manual, Chapter 30, section 50.3, “Information specific to HHA use of the ABN has been added in §50.15.4. The guidelines for ABN use published in this section and the ABN form instructions apply to HHAs unless noted otherwise.”
Maximus also ignored the sample lab ABN provided by CMS, which includes the term “PSA Screen G0103” as one of the tests listed on the sample form. It does not even mention prostate-specific antigen. Additionally, the Medicare National Coverage Determinations Coding Policy Manual and Change Report lists PSA as an abbreviation for prostate-specific antigen. It is the information in this manual that triggers the use of an ABN by a laboratory. Maximus commented that the ABN must be “written in lay terms to be understood by the beneficiary.” An extensive search of the Internet, where many patients get their medical information these days, did not reveal a single article that does not mention PSA when referring to testing for prostate disease.
Is There a Next Step for Olympic?
The hospital cannot appeal to the next level, administrative law judge (ALJ), because the amount in question is $76 and the threshold for an ALJ hearing in 2014 is $140. Putting that aside, there is no financial gain that comes from expending further resources following the appeals process, even if the hospital met the threshold. One possible course is to complain to the CMS regional office about Maximus’s seemingly arbitrary decision, which may have the benefit of obtaining more thoughtful decisions in the future.
Takeaway: Laboratories must make certain they thoroughly explain all of the information on an ABN to their patients and avoid the use of abbreviations alone in any case where they believe the beneficiary may not understand the information on the form or the financial consequences of signing the form.
