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Proposed changes in the wording of Medicare’s advance beneficiary notice to make it more patient-friendly are receiving kudos from physicians. "The proposed changes are better than what’s been there," says Bruce Bagley, MD, board chairman of the American Academy of Family Physicians. "We want the form to be relatively simple and straightforward so that everybody can understand it."
After several years of effort, the Health Care Financing Administration (HCFA) hopes to have a final revised version of the notice ready sometime this year. Medicare rules say physicians must give patients a the notice telling them that certain services, which are usually paid for by Medicare, may not be reimbursed in a particular situation. For example, this may include a laboratory test that is not covered for a patient’s specific diagnosis or extra visits to a nursing home.
While HCFA provides a model notice physicians can use, it has allowed providers to craft and use their own versions in the past. However, this practice is expected to stop once HCFA finalizes its new form.
A major complaint about HCFA’s current advanced beneficiary notice is that it contains "insurer-speak" language that many physicians say interferes with the doctor-patient relationship. Specifically, the notices tells patients that Medicare pays only for services that it decides are "reasonable and necessary" under existing law. "This can imply to some people that their doctor may be ordering a test that is not necessary," says Stephen Imbeau, MD, a member of HCFA’s Practicing Physicians Advisory Council. "What the government really means by that is that it’s considered by Medicare not to be medically necessary, which means it’s not covered by Medicare. That’s two different meanings of the same words," he notes.
HCFA’s proposed form eliminates the "reasonable and necessary" language, replacing it with a short explanation of Medicare’s coverage policies. The form makes clear, for example, that "there may be a good reason to receive a service that your doctor recommended, even though Medicare does not pay for it." Similar language is also expected to be included in a new notice that the agency is developing specifically for lab services.
Length seems to be the biggest current roadblock to revamping the form to everyone’s satisfaction. It presently is two pages long and many providers say that is too long to be useful. The American Medical Association would like to shrink the notice to just one page. To do this, it is lobbying to edit out what it says is a wordy and confusing explanation of the Medicare appeals process. "The form should simply inform beneficiaries that they have a right to appeal if the patient receives the services and Medicare does not pay, and that beneficiaries can contact Medicare for further information on appeals," the AMA noted in a comment letter to HCFA.
Consumer advocates, however, say patients should be given more detailed information up front about filing an appeal. "The patient should have this responsibility, especially since this would provide the physician and the patient with an opportunity to discuss any alternative course of treatment in the absence of the tests declined by the patient," according to the AMA.