California Advanced Gastroenterology

 
  Advance Beneficiary Notice (ABN)
      Centers for Medicare and Medicaid Services
 

This is a sample letter and is provided for educational purposes only
 
 California Advanced Gastroenterology
                                                   David J Schneiderman, MD, FACP
6403 Coyle Avenue, Suite 460           Carmichael, CA   95608                  916-863-1000     

You may have been asked to sign a Medicare authored Advance Beneficiary Notice (ABN). This is a very recent change in our practice, one that grew out of the expanded colon cancer screening guidelines pioneered and endorsed by Medicare in July, 2001.

Medicare has now agreed to provide payment for screening colonoscopy in symptom free patients who are considered at “average” risk for developing colon polyps, which are benign growths that may transform into colon cancer. The key words are highlighted and underlined.

Medicare has always paid for colonoscopy in patients at “higher risk” such as those who have bowel or certain abdominal symptoms OR in patients with colon cancer or polyps in their family OR in patients themselves who have had colon cancer or polyps in the past.As of July 1, 2001, any Medicare beneficiary can have a screening colonoscopy, and Medicare will, as with other approved services, pay 80% of what they consider an appropriate fee.

The problem arises in the pre-colonoscopy consultation, where we learn about you and you learn about us and the colon exams available. If you have bowel symptoms or one of the other risk factors described above, we expect that Medicare will pay for your office consultation. On the other hand, if you have no bowel symptoms, and your only risk factor is an age greater than 50, Medicare may NOT pay for the office visit. And, to make matters more frustrating, they will not allow you to have colonoscopy unless you have a pre-exam consultation.

Therefore, symptom free patients are being asked to sign this notice of understanding that Medicare may not pay for this visit (although they will cover your exam). We will bill them first--if they do not pay us, you may be held financially responsible for this office visit.

We are sorry for this complicated scenario. Medicare reimbursements to physician offices continue to fall each and every year, making it no longer possible for us to simply “write off” our fees when inconsistent regulations such as these come into existence. Read and/or download Medicare's ABN Document
 

Addendum: AGA Policy Update Announcement (8/13/04)
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Last week, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would change payment rates for hospital outpatient services. The proposed payment rate update would increase overall payments for outpatient services by 6.6 percent. The proposed rule implements the new physical examination benefit mandated by the Medicare Prescription Drug, Improvement and Modernization Act (MMA). The MMA authorizes Medicare to pay for a “Welcome to Medicare Physical” for all new beneficiaries – a comprehensive exam that will provide baseline information on the health status of the beneficiary, allow for early detection and treatment of diseases and provide an opportunity for physicians to refer beneficiaries to other Medicare-covered services (e.g. colorectal cancer screenings). This physical exam will allow gastroenterologists to be reimbursed for a consultation with beneficiaries about colorectal cancer screenings.

CMS accepts public comments on the proposed rule until Oct. 8, 2004. The final rule is scheduled to be published by Nov. 1, 2004.