The Hard Fact About ABNs in the ED

Weighing the difficult decisions being made in the business of healthcare.

Medicine has commonly been considered one of the most altruistic professions.  From long years spent in training to long hours spent caring for others and the perpetual drive to heal those who are hurt and comfort those who are in need, putting our patients and their families first is essentially our creed.

This is precisely why it is so difficult for some of us to carry out a specific aspect of our job.

When a patient presents to the emergency department with a need for placement, a team of professionals jump into action.  Beyond the physicians and nurses who assess for acute medical concerns, social workers, care managers, and others search for the best option to meet the patient’s needs.

Sometimes, the transition is from home to a sub-acute rehabilitation facility.  Other times, it’s from an assisted living facility to a skilled nursing facility (SNF). Occasionally, a patient could remain at home if only someone was available to assist on a regular basis. 

The patient might be surrounded by family members who are unable to meet their loved one’s needs either physically or practically due to other responsibilities, or they might be all alone. 

Unfortunately, patients usually have little to no funds in savings available to pay for the care they need.  But, there are also instances where the finances are there, but the patient is unwilling to pay for the extra care they need.

Multiple barriers can interfere with the progression of the plan for discharge from the emergency department including medical clearance, facility bed availability, patient agreement with the plan, and time of day.  Ultimately, if no option is found or agreed upon there is only one place for the patient to go – into a hospital unit bed.

And, this is the hard part. 

The patient does not medically require hospitalization.  She is being hospitalized for custodial care which can take place outside the hospital – if only there was a facility for the patient to move to.  Chapter 30, Section 50 of the Medicare Claims Processing Manual states that an Advance Beneficiary Notice of Noncoverage (ABN) can be used, “prior to providing an item or service that is usually paid for by Medicare under Part B…but may not be paid for in this particular case because it is not considered medically reasonable and necessary” or, “prior to providing custodial care.”  Presenting an ABN to the patient in the emergency department informs them that the potential financial liability will be theirs.  Which stinks. 

But what is the alternative?  If the patient doesn’t pay for the services, the hospital will.  As a physician advisor, a common lament I hear from physicians and care managers is how “mean” or “unfair” it is for us to expect the patient to pay for this type of hospitalization.  And, I agree it certainly feels that way. 

However, while in the business of caring, hospitals are still businesses.  And, like any business, providing services without reimbursement will lead to the eventual threat of closure. 

Granted, there are plenty of ways in which hospitals can curb costs and reduce spending, but we need to be honest with the fact that this is one more.  


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Juliet Ugarte Hopkins, MD

Juliet B. Ugarte Hopkins, MD is Immediate Past President of the American College of Physician Advisors, Physician Advisor for Payor Peer-to-Peer Services for R1 RCM, Inc, and a member of the consulting teams for Phoenix Medical Management, Inc., Enjoin, CSI Companies, and Pediatric Resource Group via Velvet Hammer Physician Advising LLC. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade and then developed the physician advisor role for case management, utilization, and clinical documentation at a three-hospital health system where she worked for nearly another decade. She is a member of the RACmonitor editorial board, author, and national speaker.

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