ABN forms

This past week a fragile elderly lady came into the pharmacy with a prescription for a front-wheeled walker, assuming that if she handed us the prescription we would just run the prescription through the computer like all her other medications and have her on her way in less than ten minutes. With durable medical equipment, better referred to in the pharmacy world as DME the process is not so simple. There is a plethora of different forms that need filled out, along with proof of insurance, on top of about 500 signatures that are required from the patient, and even after all this is done, it isn't guaranteed that the patients DME that they're getting will be covered. So why do these patients have to go through the hassle of filing for paperwork anyway? Medicare requires that these patients fill out this paperwork before they can receive their DME supplies. These patients are then required to fill out what is known as an ABN form. An ABN form stands for Advance Beneficiary Notice and the actual form can be found here :

http://www.dbhds.virginia.gov/documents/manuals/OCAR-CommunityReimbursementAppendixA.pdf

This is one example of a form that is commonly seen in community pharmacy practice. What is required is the reason that they are getting the prescription, along with the estimated cost of the product in case medicare decides not to cover the product, the name and information of the patient, along with their diagnosis. There is then a section for the patient to say that yes they want to receive the product or no they do not. There is also in the yes section an option that says if medicare does not cover these products they know that they are to pay the wholesaler price that was quoted to them when they picked up the product. These patients will get to take the product with them that day, and then they will receive a letter in the mail within a couple weeks from medicare letting them know whether or not they were eligible for coverage; the pharmacy also receives this product so that they can not only keep it for their records but that they can make sure that if it is not covered they get paid for their item.

Other items that are considered DME can be anything from Breast Pumps, Nebulizers, Crutches, Diabetic shoes, canes, raised toilet seats and others.

These patients will then have a folder that is kept at the pharmacy for proof of their purchase in case medicare were to audit them and ask for this information. Medicare limits coverage of certain items and services by the diagnosis. If the diagnosis on the claim is not one that Medicare covers for the item or service, Medicare will deny the claim. Many patients will be upset knowing this but it's under the control of Medicare and Medicaid services and not the pharmacy, but make sure that you are very empathetic when working with these patients, because finding out that medicare isn't going to cover something that they see as essential can be a tough time. Also from the pharmacy stand point when they are entering the prescription into the computer they need to make sure that they are using the diagnosis codes that they were given, or else medicare will not recognize the claim and reject it. So knowing all of this it is very important that not only the pharmacists but the technicians are aware of what all goes into working with these ABN forms and how they need to be  dealt with to make the experience the best they can for the patient.

More detailed information can be found at the following location:

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf