What events could trigger an Advanced Beneficiary Notice (ABN)?

An Advanced Beneficiary Notice (ABN) is utilized in scenarios where a healthcare provider believes that a service or item may not be covered by Medicare, and it informs the patient of their potential financial responsibility. The triggering of an ABN often occurs at the onset of a new plan of care, as this is the stage where a provider assesses the need for services that might be deemed non-covered.

When a patient is beginning a new plan of care, particularly involving specific treatments or procedures that may not meet Medicare’s coverage criteria, it is essential for the provider to clearly communicate this possibility to the patient. This allows the patient to make informed decisions about whether to proceed with the services and possibly incur out-of-pocket costs.

In contrast, routine check-ups, the end of a treatment plan, and elective surgeries are typically not contexts in which an ABN would be triggered as clearly as at the beginning of a new plan of care. Routine check-ups often relate to preventive care, which is generally covered under Medicare. At the end of a treatment plan, coverage issues would usually have already been addressed through prior notices or decisions made during the course of treatment. For elective surgeries, while coverage may vary, the decision to issue an ABN would more commonly arise