How does the billing process work?
When your doctor orders testing for you at a facility outside of his or her office, the facility, not your doctor, bills Medicare directly for the tests being performed. The facility will then provide Medicare with your Medicare number, the tests performed, and the diagnosis provided by your doctor.

What does "Medical Necessity" mean?
Medicare reimburses only those services that are reasonable and necessary for your treatment. Medicare also requires that all providers report information regarding the patient's diagnosis when seeking payment (to best determine whether the tests ordered were medically necessary).

If Medicare will not pay for a test, does that mean I do not need the test?
No. Your doctor bases decisions about diagnostic testing on a wide range of factors, including your personal medical history, any medications you might be taking, and generally accepted medical practices. Even if your doctor believes a particular test is "good medicine," and that the results will provide useful information to ensure the best care for you, it is possible Medicare may not consider the test to be medically necessary for patients with your diagnosis.

What is an ABN?
An ABN is an Advanced Beneficiary Notice. The purpose of the ABN is to give you advance notice that Medicare may not pay for your test. The ABN tells you which test(s) are in question, why denial is likely, and informs you that you will be financially responsible if Medicare denies payment. When it is required, you will be asked to sign the ABN before diagnostic testing is performed.

What options do I have?
You have two options when an ABN form is presented to you. 1) Sign the form and agree to pay for the test(s) if Medicare does not. You will then receive the testing or services, or 2) choose not to sign the form, accepting financial responsibility if Medicare refuses payment, and therefore, not receive the tests or services.

Will signing the ABN affect Medicare's decision to pay for the test?
No. Medicare considers a number of factors in determining whether certain tests will be covered, such as the purpose of the test and whether the test is considered medically necessary. The fact that you have signed an ABN agreeing to pay for the test(s) does not affect the likelihood Medicare will pay for your test(s).

What if I have questions?
If you have questions, you should discuss them with your physician and/or other health care provider at the time of service. You may also contact the Keystone Peer Review Organization, which was established to protect the rights of any Medicare beneficiary receiving health care services in Pennsylvania, at 1-800-322-1914.