Case Study 2 — Everybody Signs One: A Composite

Constructed. The practice and the figures are not real. The routine ABN — collected from every patient, for every service, as a matter of policy — is common enough that CMS addresses it explicitly, and it is the clearest example in this book of a patient protection turned inside out.

Background

Section 22.8 said two things about ABNs that most training omits:

A ROUTINE ABN — given to every patient, for every service, as a matter of policy — is improper.

A form everyone signs for everything informs nobody of anything, and it converts a protection for the patient into a waiver harvested by the provider.

This is a practice that had been doing it for six years and believed it was being careful.

The composite

Constructed.

A multi-physician practice with a busy front desk. Years earlier, after a run of denials that left the practice unable to bill patients for services Medicare declined, someone made a decision that was entirely rational in the moment:

Have every Medicare patient sign an ABN at check-in.

It solved the problem it was aimed at. Denials still came, and now the practice could bill the patient, and it did.

The forms were filed. The process ran. Nobody revisited it.

What the forms actually looked like

(Constructed, and unremarkable.)

Pre-printed, stacked at the front desk with the other check-in paperwork.

The service line read "office visit and any services ordered today."

The reason line read "Medicare may not pay for this."

The cost estimate line read "varies."

And the option block was pre-checked at Option 1, because a form returned with no option selected had once caused a problem, and pre-checking it had made that problem stop.

Patients signed it along with the privacy acknowledgment and the financial policy, in about four seconds, at a counter, while handing over a card.

Every one of the four requirements fails

In advance? No. Signed at check-in, before the physician had determined what services the patient would receive. The practice could not have had a specific expectation of denial because nothing had been decided yet.

Specific as to service and reason? No. "Any services ordered today" is not a service, and "Medicare may not pay" is not a reason. §22.8's example of an adequate reason — "Medicare does not pay for this test more often than once every 12 months and you had one in March" — is what specificity looks like, and it requires knowing something about this patient.

Cost estimate? "Varies" is not an estimate.

A choice? The box was pre-checked. The beneficiary selected nothing.

This was not an ABN. It was a piece of paper with the right form number on it.

What the practice was doing on claims

Reporting GA. On a substantial share of Medicare claims, for years.

GA asserts that a valid ABN is on file. Chapter 22 §22.9: a routine, blanket, retroactive, or reasonless ABN does not support GA.

So every one of those modifiers was a false statement — not a lie in the ordinary sense, because nobody at the practice understood that the form was defective. A statement made without knowing whether it was true, at volume, is Chapter 5 §5.3's territory, and it is not the first time in this book that a configuration has produced one.

And on the strength of it, patients were billed.

Where the patients came in

They paid.

(Constructed.) Some substantial number of Medicare beneficiaries, over six years, paid for services they were not liable for — because the notice that would have shifted liability to them was defective, which means liability never shifted at all.

None of them knew that. They had signed something. They assumed it meant what the practice implied it meant. A person who signs a form at a counter and later receives a bill does not go looking for the regulatory requirements the form failed to meet.

And the ones who called — Chapter 22 §22.9's 📞 On the Phone — were told a form existed and they had signed it, which ended most of those conversations.

How it surfaced

A patient's family member had worked in billing.

(Constructed.) She looked at the form, recognized what it was supposed to be, noticed that the reason line said nothing and the option was pre-checked, and wrote a letter.

Not an angry one. A letter that said, in substance: this does not appear to meet the requirements for an ABN, and if it does not, I do not believe my mother is liable for this charge.

She was right.

What it cost

(Constructed.)

Refunds to affected beneficiaries, which required identifying them — a project in itself, because the practice's records showed GA on claims and did not distinguish which patients had actually paid.

A corrected process, which meant the front desk stopped collecting ABNs entirely and the practice built a workflow for issuing them individually, in advance, with a specific reason — which is substantially more work and is the work the rule contemplates.

And a real revenue consequence going forward. Some services that had been billed to patients on the strength of the routine form could no longer be billed to anyone, because a valid ABN genuinely was not obtainable for them in advance.

That last cost is the honest one and it should not be minimized. Doing this correctly costs the practice money. The routine ABN was not merely lazy; it was profitable, and that is why it survived six years.

What it shows

First, the ABN is a patient protection and it had been inverted completely. Its purpose is to let a beneficiary make an informed choice. A pre-checked form for unspecified services with no reason and no estimate informs nobody and offers no choice — it exists solely to make the patient billable.

Second, the original decision was rational and the process never got revisited. Somebody solved a real problem — the practice could not bill for legitimately non-covered services — with a mechanism that overshot. This is the same shape as Chapter 17's modifier 59 macro and Chapter 20's waste policy: a reasonable response to a real problem, implemented as a blanket rule, running unexamined for years.

Third, GA was a factual assertion nobody evaluated. Eighth instance in this book. And this one is the most direct, because GA's entire content is "a valid ABN is on file" — there is no clinical judgment in it and no ambiguity about what it claims.

Fourth, doing it right costs money, and that has to be said out loud. Every other case study in this book has a fix that is cheap or free. This one does not. A practice that issues ABNs properly will sometimes be unable to issue one, and will sometimes eat the cost. Compliance is not always free, and a book that only ever showed free fixes would be lying.

And fifth — it was found by a family member who happened to have worked in billing. This is the sixth finding in this book that came from a person rather than a control, and the first that came from outside the organization entirely. Chapter 19's Case Study 2 said the absence of a place to say something is a control failure. This adds: when the internal places are absent, the report eventually comes from outside, and it arrives as a letter you did not choose the timing of.

The lesson

An ABN is a conversation with one patient about one service. If your process can be completed at a counter in four seconds, you do not have ABNs.

Four carry-forwards:

Look at your own form today. Does the service line name a service? Does the reason line give a reason specific to this patient? Is there a real cost estimate? Is the option block blank? Four questions, one minute.

If ABNs are collected at check-in, they are routine by definition. Check-in is before the clinical decision, and an ABN requires a specific expectation that cannot exist yet.

Never pre-check an option. It is the single most visible defect and it destroys the form's only purpose.

And accept that doing it correctly will cost something. There will be services you cannot get a valid ABN for and therefore cannot bill. That is the rule working, not the rule failing.

Discussion questions

1. The original decision solved a real problem. What should the practice have built instead, and why is it more work?

2. This is the only case study in the book whose correct fix costs the organization money on an ongoing basis. Does that change how you expect practices to behave? Does it change what you would recommend?

3. GA asserts a valid ABN is on file. Nobody at the practice knew the form was defective. Apply Chapter 5 §5.3's three-part definition of "knowingly" and say where this falls.

4. The finding came from outside the organization. What internal mechanism would have caught it, and be honest about whether any practice you know of has one.

5. The chapter says a form everyone signs for everything "informs nobody of anything." Name two other documents in health care with the same property. Are they defensible?