Advance Beneficiary Notice and Therapy Caps Clarification [05-01-13]

Filed under: Industry Updates — Editor @ 9:34 am

During the recent meeting of trade associations and other stakeholders with representatives from the Centers for Medicare and Medicaid Services Provider Compliance Group, the use of Advance Beneficiary Notice (ABN) to notify beneficiaries of the therapy caps and thresholds was discussed. There has been a change in the use of the ABN effective January 1, 2013 as a result of the American Taxpayer Relief Act (ATRA). When the therapy threshold was introduced in 2012, providers were instructed to issue the ABN to a beneficiary who was exceeding the threshold and if the claim was denied, the beneficiary could be held liable. As a result of the ATRA, beneficiaries are now protected from liability. The ABN should not be used for situations involving the exceeding of the therapy cap and/or threshold. If the therapy claim is denied, it will be provider responsibility only. ABNs should be used as they have traditionally been used such as when the provider has physician’s orders to provide services the provider believes will not be covered by Medicare.

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