Advanced Beneficiary Notices (ABN or Insurance Waivers) and Insurance Opt Out
Services performed by headache specialists may or may not be covered by all payers. Thus, it is the provider’s responsibility to know the policies for every insurance carrier they participate.
If the patient’s insurance will not cover a certain procedure, then the patient should sign an Advance Beneficiary Notice (ABN) for the procedure, collect from the patient the amount to be paid for the procedure, and then send in the bill to the insurer for reimbursement. When it is denied on the Explanation of Benefits (EOB), the provider may then send in the ABN and the insurer may respond with a new EOB that transfers the billed charges to the patient. The patient may be able to collect thereafter from their insurer.
By having patients sign an ABN, a practice may collect the charge rate, which may be considered the “usual, customary, and reasonable” amount paid, or “UCR.” This may also be called the “usual and customary” rate, or “U&C.” Determination of the charge rate will nonetheless vary by practice as the charge rate for every service rendered must equal or exceed any contractual rate by an insurer. However, a practice may discount this rate if the patient pays the day of the service. This may be called a “time of service” discount. In this context, the charge rate remains unchanged, and there is no prejudice against insurers because all insurers are offered the same discount if they pay that day for services rendered and prevents breech of the “most favored nations” clause found in many insurance contracts.
If the office visit or procedure is paid to the provider by the insurer, the provider would credit back the patient via their credit card, check, or cash. If the service is denied by an insurer, patients can appeal on their own with appropriate documentation. This may require the office note demonstrating the service, in addition to the ABN.
An Opt out of Insurance is a patient decision to agree to not bill insurance under any circumstances, i.e. they cannot even bill it themselves. This may be needed for certain procedures as well. For instance, this may occur if botulinum toxin is administered off label. The ability to have a patient sign an opt out of insurance is based on the HITECH act. Of note, there are additional nuances associated with opt out insurance and the provider should seek additional assistance prior to implementation of these protocols.
In both circumstances – i.e. an ABN or Opt out of Insurance, the provider must charge the patient their U&C, less a same day payment discount if applicable. Having a charity fee schedule may also be allowed but require additional forms and tax documentation. Existing patients who become unemployed may also qualify for this latter schedule.
Reviewing your options to address out of network patients and services that involve opt out is a start if you desire to transition to a practice that limits or removes insurance barriers and challenges.