A Medicare Waiver Is Waiting for Your Signature. Read the Estimate Before You Accept the Bill

A clinic, laboratory, home health agency or medical equipment supplier puts a paper in front of you and says Medicare may not pay. Do not treat that paper as a routine consent form. First find its title and form number. For Original Medicare, the paper may be the Advance Beneficiary Notice of Noncoverage, Form CMS-R-131, usually called an ABN.

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The ABN is a financial notice. It tells you that the provider or supplier expects Medicare may deny payment for a particular item or service. Your signature does not prove that Medicare has denied a claim. It records that you received the warning and made a choice before the item or service was provided. CMS explains the form and its use in the Medicare materials collected on the Paying for Care STL Sources page.

Who pays

Start by checking the insurance card. The standard ABN is for Original Medicare. It is not the notice used for a Medicare Advantage plan or a Medicare drug plan. If the card names a private Medicare plan, stop and call the plan at the member services number on the card. Ask which coverage decision or notice applies and whether the provider must request authorization.

If the person has Original Medicare, read the three columns before choosing anything. The form should identify the exact item or service, state why Medicare may not pay and provide an estimated cost. A generic entry such as “services” does not tell you enough to price the decision. Ask the issuer to identify the test, visit, supply or course of care in writing.

Then ask the billing office four questions: What billing code will you submit? Are you enrolled in Medicare? Do you accept Medicare assignment for this item or service? Is the estimate the full amount I could owe, or could another professional or facility bill separately? Take names and write the answers beside the estimate. Do not replace the written estimate with a verbal “usually covered.”

The papers

Form CMS-R-131 gives you three choices. One choice generally lets you receive the item or service and asks the issuer to bill Medicare, producing an official payment decision that you can appeal. Another lets you receive it without asking the issuer to bill Medicare. The third declines it. Read the wording on the actual form because your choice controls whether a Medicare claim and appeal record will exist.

Before signing, check that the patient name, issuer name, issuer phone number, item or service, noncoverage reason and estimated cost are filled in. Mark only one option. Keep a complete copy with the signature and the filled columns. If someone signs as the patient’s representative, the form should identify that role. Do not sign a blank form or accept a copy that omits the estimate page.

Ask whether the notice is mandatory or voluntary. CMS permits voluntary notices for items or services Medicare never covers, but that is different from a notice used to transfer possible financial responsibility for something Medicare usually covers. Ask the issuer to state which situation applies. If the answer is unclear, call Medicare using the number on the Medicare card before the service begins.

If the person also has Medicaid or Qualified Medicare Beneficiary protection, say so before selecting an option or paying. Special billing protections can apply. Show both coverage cards and ask the issuer how it will submit the claim. Do not decide from the ABN estimate alone.

The runway

Build a one-page claim file before the appointment or delivery. Put in the ABN, the provider’s written estimate, the order or referral, any authorization, both sides of every insurance card and your call notes. Add the later bill and Medicare Summary Notice to the same file. Match the provider name, service description and amount across the papers.

If Medicare pays, compare the Medicare Summary Notice with the provider’s bill before sending money. If Medicare denies, read the denial reason and appeal instructions on that notice. The ABN itself is not the final coverage decision. If no claim appears after you chose the option requesting Medicare billing, call the issuer and ask for the claim submission status.

Do not try to settle whether the item or service is medically necessary. That is the physician’s line. Ask the physician what was ordered and what records support the order. Do not try to decide whether a defective notice legally transferred the debt. That is the lawyer’s line. Preserve the form, bill, claim notice and your call notes.

Free help

For an explanation of Medicare choices and notices, use Missouri SHIP, the state’s free Medicare counseling program. For the St. Louis contact path and other nonprofit help, start with Local Help With Paying for Care. A counselor can help you identify the notice, prepare questions and read the Medicare Summary Notice. The counselor does not set the provider’s charge, so send every rate question back to the billing office named on the estimate.

If several payment questions are arriving at once, use Start Here: The Order to Read to separate the coverage problem from the cash-flow problem. Your first move here is smaller: identify the payer, complete every ABN field, choose whether you want a Medicare claim and leave with a copy.