Q2 2023 Newsletter - PMRG

Patient Calls: Call Center Update

Consistent with our commitment to taking care of your patients when they call into our call center, we have upgraded our call center software. The new system gives the patients better information to navigate the queueing system. When a patient reaches our call center, if their call is not answered immediately, they are told how many calls are ahead of them in the queue and their approximate wait time based on the average length of time it has taken us to resolve calls. In addition, the patients can opt out at any time and leave a message for us, which we will return within one business day. They will also be given the option to hang up and receive a call back without losing their place in the queue. The new software also allows us to better route calls to the appropriate agent. For example, since not all agents have access to the EPIC practice management system, if a patient that calls is from a practice that uses EPIC, the call will be routed to one of our agents that has access to that system.

None of these features were available in our previous software. We believe this will give your patients a better and more consistent experience when calling into our call center.

Even with these upgrades, there will be some patients that are upset. We are highly sensitive to this; we appreciate that a patient that has a poor experience or is upset with the call may associate that experience in a negative way with your practice. In extreme circumstances, this can result in patients leaving your practice.

As we evaluated the source of what upset patients most, we discovered that the biggest issue was related to the patient receiving a statement showing unexpected expenses. Very often, this is because they did not fully understand the costs associated with their policy, or how their deductibles work. This can be—and is often—very confusing! However, after digging a bit further, we discovered that the single largest source of unexpected expenses leading to upset patients is related to whether medical or vision insurance was billed. It is important that patients know upfront which insurance will be billed and all associated costs. We recently sent a communication out about this issue. That article is on our website and can be found here. If you have further questions on this, please contact Donna or Jana so they can explain and instruct you on best practices.

As has always been our policy, we are happy to call patients that have had a poor experience with our call center. We appreciate how important it is to take care of your patients in such a way that they fully understand why they received their statement, and that they leave the call satisfied with their experience of interacting with us.

Advanced Beneficiary Notice of Non-Coverage (ABN)

As providers, it is important to ensure you are paid for the work you do. There are times when care is not covered by Medicare because they deem the service not medically necessary. In these circumstances, it is vital to make sure that you communicate the likelihood that the service will not be paid for by Medicare and give your patient the option to receive these services but pay for them out-of-pocket.

This communication is called an Advanced Beneficiary Notice of Non-Coverage, or ABN. If the potential patient’s financial obligation is not communicated properly with the use of an ABN, the provider may be held financially liable for the service and payment could be denied. By using an ABN, it allows the provider to transfer the financial responsibility for the service to the patient when the provider furnishes a non-covered service.

The following are circumstances when the provider will need to issue an ABN to transfer the financial liability to the patient if the service is denied by Medicare as not medically necessary:

When a Medicare item or service is not considered reasonable or necessary
- Not indicated for the diagnosis.
- Experimental and/or investigational.
- Exceeds the number of services allowed in a specific period for that diagnosis.
When providing custodial care
When outpatient therapy services exceed therapy threshold amounts
Before providing a preventive service that exceeds frequency limitations

After having a patient sign the ABN for services that are considered non-covered, the claim requires a modifier to indicate that the ABN is on file and the patient can be billed for the financial responsibility. These modifiers include:

GA – Wavier of liability statement issued as required by payer policy, individual case
GX – Notice of liability issued, voluntary under payer policy
GY – Notice of liability not issued, not required under payer policy
GZ – Expect item of service denied as not reasonable and necessary
GK – Reasonable and necessary item/service associated with GA or GZ modifier
GL – Medically unnecessary upgrade provided instead of non-upgraded item, no charge, no ABN

It is not necessary to have the patient sign an ABN when you provide a non-covered service under Medicare Part B. An example of this would be refraction. A refraction is not a covered service by Medicare so an ABN would not be appropriate in this situation.

Below is a link to the Medicare article explaining the use of an ABN as well as a link to the ABN form for Medicare Part B Claims.

Click here to access the article about Medicare Advance Written Notices of Non-coverage

Advanced Beneficiary Notifications apply to Medicare Part B only. To determine what services are covered and what services are not covered when billing a Medicare Advantage Plan and/or a Commercial insurance plan, you will need to check your contract language and/or check for a Medical/Reimbursement policy specific to that plan. Most Medicare Advantage plans and Commercial insurance plans do not recognize Medicare ABN’s.

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