QIC Says Abbreviation Rendered ABN Invalid

According to a recent story on AIS Health, Olympic Medical Center in Port Angeles, Washington has reported that the Qualified Independent Contractor (QIC), Maximus, issued an unfavorable reconsideration decision on the issue of the validity of an Advanced Beneficiary Notice (ABN) for a lab test.  According to the story published May 1, 2014, the QIC issued a denial letter at the reconsideration stage of appeal indicating that the acronym PSA for the prostate antigen screening laboratory test was not sufficiently written in “lay terms” that could be “understood by the beneficiary.”

While an Administrative Law Judge (ALJ) could potentially overturn this QIC decision, it is an important compliance lesson for providers to avoid the use of acronyms in ABNs, even those that are commonly used.

ABNs are notices provided to Medicare beneficiaries when the provider believes that Medicare will not pay for the service because it is not reasonable and necessary, it is considered to be custodial care or because the service involves outpatient therapy services in excess of the therapy cap that do not qualify for an exception.  ABNs must also be used for home health services when the patient does not meet the requirements (e.g., homebound status) or for hospice services where the patient is not terminal.

More information about the appropriate use of ABNs can be found in the Centers for Medicare & Medicaid Services (CMS) Medicare Learning Network booklet on Advance Beneficiary Notice of Noncoverage (ABN) available on the CMS website at:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf

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