Reference no: EM133040844

Instructions: Review the three (3) scenarios, research the main topic, and provide your answers to the question(s) for each scenario directly on this worksheet. 

Scenarios

1) Advance Beneficiary Notice Scenario 

A patient presents to the hospital for an outpatient Magnetic Resonance Imaging (MRI) procedure. Upon arrival, the Patient Access Registrar presents the patient with an Advance Beneficiary Notice (ABN). The ABN indicates that the diagnosis submitted by the provider does not meet Medicare criteria and will most likely be denied. The estimated cost of the procedure is $1800. 

The patient indicates that they would like to proceed with the MRI. They understand that they may need to pay for the procedure upfront, but would like to have Medicare billed for a final determination of payment. If Medicare does pay, they expect to receive a refund for their pre-procedure payment. 

a) The patient is asking which option to choose. To be compliant with Medicare Rules, what guidance is provided in the ABN instructions? 

b) What are the consequences for the facility if the ABN is not presented to the patient prior to services/treatment?

c) If the patient chooses to select Option 1 and payment is denied, does the patient have any recourse?

2) Medicare Eligibility Scenario

At the time of each visit, the registrar needs to check the patient's Medicare eligibility. The registrar needs to perform four (4) tasks to validate eligibility on the initial encounter and periodically during subsequent visits.

In the table provided, enter your responses to the following:

Column A - Briefly state the four (4) tasks 

Column B - Indicate one reason why each step is important

Column A-    List 4 Medicare Eligibility Tasks	Column B-  Purpose of the Task

3) Medical Necessity Determination Scenario

A patient is currently being evaluated for a rare debilitating condition. Recent research has indicated some success in obtaining relief when treated with an experimental drug during a clinical trial. The drug is currently under review by the FDA. The research indicates a maximum of two (2) administrations of the drug weekly for the first two weeks. Protocol further specifies that the drug be administered by a licensed medical doctor in the provider's office. 

The provider would like to start the patient on a regimented treatment plan that requires administration of the drug three (3) times weekly given the patient's rapidly deteriorating condition. The provider is planning to be on vacation for the next two weeks and has requested one of the first year residents to administer the medication. The resident works primarily at the hospital in the Emergency Room so therefore scheduled times to meet the patient in the Emergency Room on Monday, Wednesday and Friday for the next two weeks. 

The patient's provider submitted a prior authorization request to the patient's insurance carrier and received a denial.  What are the reasons the request was denied based on Medical Necessity criteria?

State the medical necessity criteria that resulted in the denial and the reason why the criteria was not met:

Column A Medical Necessity Criterion	Column B Indicate why the criteria was not met based on the documentation