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Lab's Non-Coverage Notice Deters Medicare Patients

Cheryl Clark, for HealthLeaders Media, June 12, 2012

Non-compliant language
However, the version of the form Quest is distributing does not inform patients that Medicare covers the test every three months. The form includes this language that Medicare officials say is problematic:

  • "Medicare does not pay for these tests for your condition."
  • "Medicare does not pay for these tests as often as this (denied as too frequent)."
  • "Medicare does not pay for experimental or research use tests."
  • The "estimated cost" is $66.

This form "does not comply with the standards for valid ABN issuance," Medicare's Jennifer Smith, director of the Division of Appeals Policy and Evelyn Blaemire, Senior Health Insurance Specialist, said in an e-mail response to HealthLeaders Media.

The rule specifies that the provider "must clearly indicate on the ABN which portions of the pre-printed information are applicable."

The Quest form has been in place for about two months in a region covering eight Southern California counties, or about 21 million people. Of those,  about 13% are Medicare beneficiaries. More than 20% of Medicare beneficiaries are estimated to have diabetes, or about 554,000 people in this area who should receive quarterly A1c tests.  Quest is one of two major labs serving this population.  The other, LabCorps, does not use these forms, Speckart says.

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2 comments on "Lab's Non-Coverage Notice Deters Medicare Patients"


cheryl clark (6/15/2012 at 2:38 PM)
Mark [INVALID] the ABN form being distributed lists all three reasons, side-by-side, in the boxes.

Mark Sires (6/13/2012 at 4:55 PM)
If Quest's ABN indicates all three reasons, then it is noncompliant. If it only indicates that Medicare doesn't pay as often as this (which is the REQUIRED verbage per CMS guidelines), then this story is wrong. This is what has to be done. There is no mechanism for Quest, or any other laboratory, to verify the last time a patient had the test done. Therefore they have to provide an ABN for every time limited test. Medicare patients are free to get their testing done at any laboratory, so they can't assume that the last time they performed the testing was the last time the test was performed on this patient. The REAL story is that CMS implemented these time limited tests with no mechanism for laboratories to verify coverage. This is a CMS problem, not a Quest problem. If CMS wants to fix this, then they need to change the rules so a laboratory only has to provide the ABN if the test was performed by their lab within the limited time. If CMS determines that the testing was performed at another lab within the limited time frame, then the lab should be free to bill the patient even though an ABN was not produced.