Jeff Gatewood

I've met physicians who think they are complying with the requirements of the Medicare Annual Wellness Visit (AWV), but don't realize they have to provide a personalized plan at the time of the patient visit.

Providers must provide at least one “action” for all health risks discovered for the patient from the required pre-visit Health Risk Assessment. The complete “personalized care plan” must be created and given to the patient at the time of the visit and cannot be sent later.

1. Written 5-year to 10-year screening schedule, health status, screening history, and age-appropriate preventive services covered by Medicare;

2. Personalized health advice given to the individual;

3. Referral to health education or preventive counseling services or programs aimed at reducing identified risk factors; and

4. Community based life-style interventions, i.e., weight loss, physical activity, smoking cessation, fall prevention and nutrition, etc.

Therefore, practices should engage an IT service to create all the “actions” that the practice pre-determines for most potential health risks and personalize them to specific local and in office sources.

Actions can further be identified, for example, as:

1. Referral to local senior center for exercise programs with specific phone and location information provided.

2. In-office appointments for smoking (G0437), obesity (G0447), or alcohol counseling (G0443) reimbursed on new preventive codes.

3. Referral to office-recommended orthopedist, eye specialist, or nutritionist.

4. Return appointments to go over nocturnal problems, allergy, falling, or other concerns discovered on the Health Risk Assessment as they are offered by the provider.

CMS specifically does not accept “general” health recommendations, such as “exercise more, eat less, smoke and drink less, etc.” Providers must search their local referrals databases and create a library of community programs with details on their location, phone, etc., to give to the patient at the time of the visit.

It is important to note that the provider should not specifically address any of these concerns at the time of the visit since they are not reimbursed if provided at that time. The AWV is only reimbursed for “planning and referrals” and not for any treatment or even prescriptions. If an emergency condition is discovered, the provider is allowed to and should extend the time and bill for a 99213 or other appropriate code with a -25 modifier to treat that condition on the same day.

One caution is that CMS is launching audits under its Recovery Audit Contractors (RACs) to discover improper or incomplete provision of the AWV. Many practices are simply billing for the AWV without providing a detailed and personalized plan at the time of the visit.

Providers should consider a qualified IT partner to create these personalized plans with pre-determined local referrals and in-office actions to pass an audit and prevent recapture of the AWV revenue.

Articles

Many medical practices are billing for Medicare's AWV without providing a detailed and personalized plan at the visit. Here's what they should do.

Meeting Medicare AWV Compliance Requirements

Paying staff a bonus for identifying eligible patients and scheduling a Medicare Annual Wellness Visit (AWV) may dramatically increase the practice revenue.

The tremendous revenue opportunities for Medicare AWVs allow for incentive bonuses for generating those visits.

A practice could easily justify a $25 bonus for identifying an AWV eligible patient and scheduling a visit that generated over $200 with a 15-minute to 20-minute minute encounter, far more than the average $70 level 99213.

I've heard of a practice that instituted this method recently and generated over $50,000 in annual revenue.

It has been well proven that patients are not requesting the new Medicare AWV even though it has no copay. Practices also have not been successful at scheduling the AWV.

The documented reasons have been that the patients do not immediately see the AWV as beneficial or desirable. They are told they will not receive any direct medical treatment and the visit does not include an annual physical.

The physicians say they are confused about the requirements and are not prepared to create and deliver the required components of a 5-year to 10 year benefit schedule and a comprehensive care plan.

Therefore, over $200 per patient from no copay initial benefits is literally wasted and unclaimed.  Plus, the opportunity for an average of $200 for return visits for discovered risks is also never generated.

From a patient welfare standpoint, their risk conditions are untreated and ultimately develop into more serious conditions. The patients and the healthcare system ultimately pay the price for this egregious omission.

Practices need to start looking at the AWV as a business and healthcare opportunity. In the auto industry, garages run oil change specials to encourage owners to bring in cars and then get a detailed analysis of all the other maintenance and repair problems, like tires, batteries, belts, etc.

A practice cannot run an “AWV Special,” but they need to look at ways to encourage and generate more appointments.  Rewarding staff for their initiative in scheduling an AWV may be the answer.

Medical practices need to start looking at the AWV as a business and healthcare opportunity. Offering staff bonuses to schedule the visits may help.

Staff Bonuses May Increase Medicare AWV Scheduling

The Medicare Annual Wellness Visit (AWV) is not subject to incident-to billing. It can be provided by a physician assistant, nurse practitioner, or clinical nurse specialist without the assistance of an MD or DO.  It cannot be billed incident-to by the MD or DO under their NPI number.

The practice may decide to have the pre-visit Health Risk Assessment  along with the required physical vitals (blood pressure, height , weight, pulse ) collected by a medical assistant (MA) or licensed nurse practitioner (LPN) and then ready for review by the MD or DO. CMS allows this preliminary collection of data by an MA or LPN under the supervision of an MD or DO, or even a PA or NP.

The billing authority then reviews the data and makes any medical decisions, usually in 5 minutes to 15 minutes, and bills under their appropriate NPI.

It would not be really cost effective for the provider - whether an MD, DO, PA, or NP - to spend the whole time collecting the data, when they only need to provide the medical decisions related to the visit.

This may open up the opportunity for practices to provide AWVs on days when the MD or DO is not in the office on certain days during the week.  The MA or LPN could consolidate the HRA data and present it to the PA or NP for review and medical decisions before billing.

Since the AWV can generate a minimum of $166, the practice revenue would be about $141 at 85 percent for the G0438 code. There is also the opportunity for billing the annual FOBT colon cancer screen for about $22 and the annual depression and alcohol screens for $34 at about $17 each.

Some practices may choose to schedule these AWVs on days when the PA or the NP is available, but not the MD, so that significant revenue is generated for these benefits on a day when the practice may not normally generate the same revenue as days when the MD or DO is in the office.

I have even seen instances when a practice employed a part-time NP or PA to come in certain days just to provide the AWV. If efficient scheduling is created, an NP could provide six AWVs, for example, with screens and generate almost $200 each, $1,200 per day, or over $60,000 annually for one day per week.  This is a significant return on investment for the practice.

Think about scheduling AWVs efficiently and coordinating PAs or NPs to provide them. Your practice and your patients could both benefit.

Some efficient and coordinated scheduling of the Medicare Annual Wellness Visit can benefit patients and your medical practice.

Maximize Billing Opportunities for the Medicare AWV

Medicare patients bear little of the expense for their own care. So as a result, they have little incentive to participate in preventive care.

Physicians are not required by CMS to complete a Health Risk Assessment (HRA) or provide wellness visits for their Medicare patients even though they now have substantial reimbursement incentives for doing so.

Private employee health plans often require the regular submission of an HRA and actual participation in health risk prevention programs. Employees are often penalized or even terminated if they do not comply.

Should Medicare patients be offered the option of either an incentive or a penalty, like private employees, to participate in preventive medicine? Should physicians be required to provide wellness and preventive benefits?

Here are proactive suggestions to increase participation for patients and physicians:

1. Medicare patients who complete an HRA and a resulting wellness visit will receive a modest $5 or $10 reduction in their monthly Part B deduction ($60 to $120 a year).

2. Medicare patients who do not participate in at least an annual wellness visit will pay a 5 percent increase in their copays from the standard 20 percent to 25 percent.

3. Physicians that do not complete HRAs and wellness visits for at least 25 percent of their eligible patients would face a scheduled reduction in Medicare reimbursement for all services. (The practice could actually qualify to drop patients who refused, therefore increasing the chance of participation)

It has long been established that reducing copays increases participation in benefits, such as mammograms, flu shots, etc.  CMS eliminated patient copays for the new preventive benefits and wellness visits.

Providing reimbursement without copays is also very attractive to physicians.

The new preventive benefits and especially annual wellness visits have had very little participation. Less than 7 percent of eligible patients last year and not many more this year 

. A big problem is that physicians have also not participated. A recent report says 

66 percent are ill-prepared to create personalized plans

 and 71 percent are unprepared to engage patients throughout the year with communications that that help them adhere to their personalized plans.

One often-heard complaint is that patients do not want to come in just to get a wellness visit without actual physician treatment. This can be overcome if physicians would collect the pre-visit HRA electronically and then coordinate the wellness visit with a problem-oriented visit for the patient. Providing both encounters on the same day can generate $250 or more for a 30-minute visit.

The average cost for Medicare patients is now over $9,000 annually and approaching $10,000. Medicare is estimated to be bankrupt in 2021. Reducing treatment expense $1,000 by providing prevention could save $47 billion now and trillions in coming years.

The present system is clearly not working.

Presently, physicians and patients are primarily are involved in treatment, not prevention. Is it time to swing the pendulum the other way?

Presently, physicians and patients are primarily involved in treatment, not prevention. Is it time to swing the pendulum the other way? 

Author | Jeff Gatewood

Articles

Meeting Medicare AWV Compliance Requirements

Staff Bonuses May Increase Medicare AWV Scheduling

Maximize Billing Opportunities for the Medicare AWV

Should Preventive Care Be Required For Medicare Patients?