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Lab's Non-Coverage Notice Deters Medicare Patients

Cheryl Clark, for HealthLeaders Media, June 12, 2012

Quest corporate spokeswoman Wendy Bost in Madison, NJ, said in an e-mail the ABN form Quest issues "is consistent with CMS guidelines, and in fact much of the language in our forms (including the language you have cited in your e-mail below) is verbatim from these guidelines. We are now in contact with CMS."

She added, "Denying clinically appropriate laboratory testing to Medicare beneficiaries serves neither our patients nor our business, and is not our practice."

Bost did not respond to a question about whether the policy is being implemented in other Quest divisions besides Southern California.

Impact on physician performance measures
The impact of Quest's policy has ramifications on physician performance metrics as well. Medicare's Physician Quality Reporting System or PQRI, penalizes reimbursement for doctors with lower percentages of diabetes patients who obtain quarterly A1cs.

The Society of Clinical Endocrinologists in Jacksonville, FL, had not heard about the Quest's ABN language. But its director of member advocacy, Anita Sumpter, said after seeing the form, "The physicians may need to start informing their patients prior to them going to have blood work done what is an ABN and why Quest is presenting it to them.  They may also need to work with Quest to get them to provide a better explanation why they are providing the ABN to the patient.

"Quest has to do their due diligence in appealing denied claims before billing the patient for denied services.  They could get into serious trouble with this type of practice because CMS does not recommend routinely providing patients with ABNs."

Speckart says the issue has created enormous headaches for his office, which sees a large share of diabetes patients. Quest's form "has inserted another layer of difficulty in a practice already grappling with an increasing number of regulations," he says.

For Medicare officials Smith and Blaemire, the bottom line is patient care. "When the ABN is issued consistent with Medicare policy, it serves to protect both providers and beneficiaries from unexpected financial liability and should not deter beneficiaries from receiving covered care that is medically reasonable and necessary," they wrote.

They said they "will follow up with Quest to re-educate the provider on the delivery requirements for ABNs."  They add, "providers must exercise caution before adding any customizations beyond these guidelines, since such alterations could result in the ABN being invalidated and make the provider (in this case Quest) liable for non-covered charges."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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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.