Failure to Use Correct ABN Form When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the correct Medicare Advance Beneficiary Notice of Non-Coverage (ABN) to a resident whose Medicare Part A skilled coverage ended while the resident remained in the facility. The facility census was 162 residents, with three residents reviewed for beneficiary notifications, and documentation showed that one resident’s Medicare Part A last covered day was 10/31/25. Instead of using the required ABN Form CMS-10055, the facility issued Form CMS-20052 (11/2017). During interviews, an administrative staff member and a social services staff member both confirmed that the correct ABN Form CMS-10055 was not provided to this resident. The facility had an undated policy titled “Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055 (2024),” but it was not followed in this case. This deficiency was identified through record review and staff interviews, which established that the resident did not receive the appropriate standardized notice of Medicare non-coverage at the time their Part A coverage ended, despite the facility having a policy referencing the correct ABN form.
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