I post this question because so many people I speak with are totally unfamiliar to this very important piece of paper. Nearly three years ago my husband was told he needed a PET Scan....he checked with both his Oncologist and the hospital to sure this would be covered. He also contacted Medicare and was informed pre-approvals were not necessary. Since he has never had issues with the multitude of scans he had previously he didn’t question further. When he was on the table fully prepared for the scan, someone came in and he was told he had to sign a Medicare waiver. They simply explained there was a possibility Medicare would not pay. Since he was assured he was covered, he signed. Medicare refused to pay the 10K bill. We thought it might have been a coding error. He disputed with all necessary paper work (Oncologist report, etc) and Medicare still declined. Now he’s almost a year into this and the hospital referred the bill to a collection agency.
After days of continual research I came across the ABN (Adavanced Benificiary Notification). All medical providers, hospitals, labs, physicians, nursing homes etc. MUST provide this form if they feel Medicare won’t pay. Not a generalized waiver, but the form provided by CMS. This form stipulates a dollar amount that must be filled in and an explanation to the patient as to why this may not be covered. Also, it must be presented in advance so the patient can make an informed decision. Medicare typically won’t volunteer the information about the ABN....you have to dig, and dig....and after that hope you get a well schooled agent to tell you how to move forward.
Once again he disputed the claim saying he never signed the ABN and after Medicare investigating this we were informed that the claim was still denied but the hospital had to absorb the cost. The hospital still insisted we were responsible....and after contacting Medicare again.....they reminded the hospital they were in violation of contractual agreement. Our account now has a zero balance.
The health field that accepts Medicare are all well aware of this, but the patient is not and it seems it’s a well guarded secret. This happened at a top rated hospital, so consumer beware.....the ramifications can be devastating. I hope this two year journey helps someone in a similar situation.