In the Case of Rx Home Care, Inc.

A home health agency's skilled-nursing visits (pouring medication into a pill organizer, twice a month, for a dually-eligible Medicare/Medicaid beneficiary) weren't a skilled service and weren't covered by Medicare — filling a pill organizer doesn't require a skilled nurse's own training. The agency argued the beneficiary should be liable for the cost — but the Council held the AGENCY liable instead, because the advance written notice on file was more than two years old by the time the disputed services were furnished.ruleHHS Departmental Appeals Board, Medicare Appeals Council — In the Case of Rx Home Care, Inc. (November 3, 2009)

An ALJ had initially ruled fully in the beneficiary's favor, finding the services covered; the provider itself appealed that favorable outcome to the Council, which reversed — finding the services weren't skilled, and then separately finding the provider (not the beneficiary) responsible for the resulting bill.

An Advance Beneficiary Notice only shifts the cost to the beneficiary if it was given for the specific service, before it was furnished, and — for an ongoing course of treatment — renewed at least once a year. A stale or one-time notice doesn't cover services furnished long after it was signed.

If the provider is trying to bill you for a denied service and the ABN you signed is old, or was for a different service, that's a real, citable argument for why you — not the provider — shouldn't be the one responsible for the cost, separate from whether the service itself was covered.

The Council's own liability analysis is a separate, second step from the coverage question — even after concluding a service isn't covered, it still has to ask who's responsible for the resulting bill, and the answer to that second question doesn't automatically default to the beneficiary.

This case is also a reminder that a provider can be the one asking for Council review, not just the beneficiary — worth knowing if you're trying to gauge whether a favorable lower-level decision is really the end of the matter.