Answers to Important Questions about Changes in Medicare Coverage of Laboratory Testing
What is an Advance Beneficiary Notice (ABN)?
Medicare will only pay for testing that it considers medically necessary. Medicare determines the medical necessity of the test by the diagnosis that your physician provides. In some cases, Medicare will determine that the test ordered is not medically necessary for your diagnosis and therefore Medicare will not pay for the test. In other cases, Medicare will determine that the test has been ordered too many times for your diagnosis and, therefore, Medicare will not pay for the test (you may have heard this referred to as a frequency limitation.) When your doctor or Sonora Quest Laboratories has reason to believe that Medicare will not pay for your test for either of the above-mentioned reasons, you will be asked to review and sign an Advance Beneficiary Notice of Noncoverage (ABN).
What is the purpose of an ABN?
The purpose of the ABN is to give you advance notice that Medicare may not pay for your test(s) and allows you to participate in your health care decisions. The ABN helps to explain to you what test(s) you may have to pay for and why Medicare is likely to deny payment. ABN related denials are:
- Medicare does not pay for these tests for your condition
- Medicare does not pay for these tests as often as ordered by your doctor
- Medicare does not pay for experimental or research use tests
Sonora Quest Laboratories will provide you with the estimated cost of the test(s). It is then up to you to decide if you want to receive the test and bill Medicare knowing they may not cover the test (Option 1), receive the test and not bill Medicare (Option 2) or if you do not want to receive the test (Option 3).
Why am I asked to sign the ABN?
Each time there is reason to believe that Medicare may not pay for your test, you will be asked to review and sign an ABN.
What happens if I choose Option 1?
Sonora Quest Laboratories will bill Medicare first for tests performed. If Medicare denies payment you will receive a bill for the denied service(s). You will be responsible for payment for these tests as you agreed by signing the ABN.
How will I know how much I will have to pay for a laboratory test?
Sonora Quest Laboratories will provide an estimated cost to you for the tests your doctor ordered.
If Medicare will not pay for a test, does that mean that I do not need the test?
No. Medicare may not consider the test to be medically necessary but your doctor may believe the test will provide useful information in order to provide the best care to you. We recommend you contact your doctor with any questions about testing.
What happens if I choose Option 2?
Sonora Quest Laboratories will not bill Medicare for tests performed. You will receive a bill for the service(s) performed. You will be responsible for payment for these tests as you agreed by signing the ABN.
What happens if I choose Option 3?
Sonora Quest Laboratories respects your right as an informed health care consumer to refuse any laboratory testing that was ordered by your physician. Therefore, if you check Option 3, Sonora Quest Laboratories will not perform the laboratory tests indicated on the ABN. We do recommend you inform your doctor of your decision not to have the tests performed.
For additional information about Medicare coverage visit www.cms.hhs.gov or call 800.MEDICARE (800.633.4227).
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