Medicare Annual Wellness Visit Required by Law?

[GANS1110]

Trying to determine if medicare patients have the right to refuse the annual wellness visit or is it mandated by law?

[javmd]

As a retired internist, I'm very familiar with AWV coding, and an AWV is certainly not "required by law".  However, it may be required by your physician for several reasons: strongly encouraged by Medicare, required by physician's corporate (hospital system) employer, monetary incentive (high reimbursement by Medicare for minimal physician work), grading of physicians by metrics.  The charge entered on the claim filed with Medicare is by the HCPCS code G0439, which should be reimbursed in full by Medicare. Medicare's required components of the AWV are primarily questions and heath risk assessments, as well as promotion of Medicare's screening benefits, such as mammagrams.  There were never any required physical exam components, so it was left up to the physician to determine what would be done, which was highly dependent on time. To get a preventive care physical exam, the physician could use the CPT code 99397, which would never be reimbursed by Medicare. However, there is a way the physician can address new medical complaints, followup of chronic problems or even a complete exam by coding an "evaluation and management" CPT code 99214 or 99215 with a -25 modifier indicating that service was done at the same time as the AWV.  It's up to the physician to allow for sufficient time to do both, but the employer may not allow physicians to control their schedules.  The additional E&M service with -25 modifier should be covered by Medicare with the usual co-pay which would covered by the supplemental.

[JoeH212827]

Everyone interested in this topic might benefit from an article in today's NPR news.

https://text.npr.org/1208105347  

[GailL1]

It would help if beneficiaries (and media that publish articles) knew exactly what the Medicare “annual wellness visit” covered and what is NOT covered.

Medicare.gov - Annual Wellness Visit Coverage

Too often we takes words/phrases and attach our own meaning when, in fact, the government uses the terms as an actual definitive thing.

Same with the Welcome to Medicare Visit

Same with the Annual Wellness Visit

Each of these are actual specific coverage things and coverage is described on Medicare.gov   And that is what the doctor is paid for under the appropriate billing code for each of these review visits.

Doctors should know exactly what is covered under these definitions and bill accordingly.  Yes, another visit may have to be scheduled to look at or handle those [whatever] matters that come up during these type of doctor review visits.

Under Medicare, consider these type visits as a beginning in the process - the getting to know you, the developing of a plan or schedule.

Every doctor needs this in order to know you and your health needs.  Then there is that stuff that the doc is asked to quiz you about like Do You Have A Living Will or Healthcare Directive.  Or like the Mental Health Questions which they are asked by Medicare to cover.

Now what I am posting here is specifically about Medicare however, the NPR article seems to be talking about the (no out of pocket) preventive service of a wellness check under the ACA.  And again, that has its own definition of coverage.

Here is what CMS tells doctors about these MEDICARE Wellness Checks - the Welcome to Medicare and the Annual Wellness Visit.  Coverage is pretty much cut and dried - but now if you think that isn’t what it is suppose to cover - take it up with the government.

CMS.gov -Medicare Learning Network - 03/23/2023

[MaryM373887]

I’m starting to read the fine print. It’s sad. I would think an annual wellness exam or a welcome to Medicare exam would be just like the annual physical I’ve been getting for the past 25 years. But it’s not even close.

[RobertS137863]

Am I glad to see this discussed! Because my wife and her daughters who live nearby are all physicians, I balk at wellness visits. After innocently going the first year, PCP’s office has tried numerous things including lying by saying they’re mandatory. Most recently had some young male (hired specifically for this purpose?) call out of the blue to ask questions my PCP “forgot to ask on my last (4-5 months prior) visit”.

Medicare fraud anyone?

On another quasi related note: after developing an allergic respiratory response to Covid, PCP prescribed an expensive inhaler. My supplemental plan covered the initial prescription, but nothing thereafter. Upon needing a refill and leaving numerous VM’s to PCP for help without response, my only option was to drive 1/2 hour each way to his office to get a prescription for an older equally effective med. It cost 1/10th what the first one did. 

Medicine in the US isn’t dying, it’s dead. Wife’s daughters tell countless horror stories. 

[roberte127682]

its all about the $$

[JoeH212827]

This isn't a laughing matter to me.  My healthcare provider sold out to a big St. Louis for profit organization. Now they are taking steps to increase profit, and one of those steps is to require a Medicare annual wellness visit with each routine physical. For 3 or 4 years they honored my request that I didn't want or need the wellness visit. Now they have decided that I must take it or else.... 

My last physical 1st the nurse told me my insurance might not pay for my physical if I didn't take the wellness visit. I called my insurance they didn't even know what she was talking about.

I refused, my Doctor told me Medicare WANTED them to give the exam. I called Medicare, they said they didn't want or require us to do anything, not even go to the Doctor.

Since they aren't allowed to do a Physical and wellness check on the same visit, they charge you for a co-pay and your insurance provider for an additional office visit, which you don't get.  The Wellness check only consists of a questionnaire asking if you needed help recently to do daily tasks. My Doctor sees me twice a year and KNOWS my physical condition .According to Medicare any charges to medicare that you don't want or need is billing fraud. I believe medicare fraud is so rampant it;s impossible for Medicare to address the issue.

So I'm left to either stop taking a physical of let them use my account to defraud Medicare. 

There is another provider here locally bur I have been going to the same place since mid 70's and all my records are there.

[moreorp]

Have you reported this to Medicare yet?

[LkA153143]

I seriously object to these wellness exams. My conglomerate doctors office holds my meds at bay, not approving refills u less I hv a wellness exam scheduled. The appt for this next one will not take place until the end of 2022. You cannot discuss existing conditions or concerns or u are charged and it’s no longer a wellness exam. No list of questions that r relevant r asked. This, in my opinion is simply a money making scheme. I was told it was to make certain I didn’t hv any health concerns and to make certain they were not just refilling meds for patients who do not see their doctor. An organization that size doesn’t know me and doesn’t care. $$$$$

[aruzinsky]

---

@GANS1110 wrote:

Trying to determine if medicare patients have the right to refuse the annual wellness visit or is it mandated by law?

---

Just out of curiosity, what kind of punishment did you envision for violating this hypothetical law?

[moreorp]

Well, for one thing my doctor refuses to see me anymore because I don’t want to  answer all of those privacy-invading questions for the Medicare Wellness Visit.

[PatriciaH335936]

Malignant ignorance.  Yet another example of the hubris, temerity, disrespect, lack of ethical & moral compass in this perverted " healthcare system" .    As a career professional that spans 45 years in medicine , always an advocate for my patients-----I am embarrassed for you.

[moreorp]

Thank you very much for your post. I wholeheartedly agree with you. My health system in Indiana is quickly going downhill. I am strongly opposed to doctors forcing anything on their patients as they are doing now with the AWV.  My former doctor refused to see me anymore because I didn’t want to do the invasive AWV, and I think my new physician is going to do the same.  
So now where do we go to find a caring physician and not a bully?

[EveRH]

I transitioned to Medicare last summer, and never heard of any mandatory screenings, nor do I intend to have any.

[CindyV865042]

I had this last year thinking it was mandatory - which I now know IT IS NOT. It was the biggest waste of my time! It's more like a survey. Ex.: do you wear a helmet when riding a bike? do you have safety handles in your tub or shower? do you wear a seat belt while driving? do you know the ratio of fat, protien and carbs in your diet? It was ridiculous!!!

[moreorp]

My doctor won’t see me anymore because I won’t do Medicare Annual Wellness Visits.

[peacewoman]

I just left a practice because of this requirement.  They refused to refill my meds if I wasn’t seen by a pharmacist.  The doctor told me her reputation would be downgraded if her patients didn’t abide by this rule.  She said Medicare doesn’t share that information.  I’m leaving anyway because I don’t like being forced to do something.  It should be my choice.

[JoeH212827]

Your comment about being seen by a pharmacist was a surprise to me. Can a pharmacist refill without a renewed prescription from a Doctor?  I went to an Urgent care facility not associated with any Hospital they gave me a 6 month refill, not sure what after that.

As to explanations from Dr.s and Nurses, I've been told every lie in the book. I called Medicare and they said they provide the Wellness exams but don't require or even care if you use them or not. She said my Dr. was misinformed because He told me Medicare WANTED them to do the Wellness exam every year. It's all to do with the extra profit. Even if any of the questions on the wellness exam applied to me I certainly wouldn't go to a Internal medicine Dr. Would He give me medicine to help me feed myself or get dressed. The U.S. Government needs to step in quickly !!!

[moreorp]

I agree. Does Medicare even know or care about these abuses of patients by their “trusted” providers?

[GailL1]

Some docs are now participating in new CMS initiative programs which attempts to reward them for keeping the beneficiary healthier - especially those who are located in areas where there is a health equity problem.

If your doc is a member of such a program - most likely all their patients are under it too - 

So you might have to find a new doctor if you don’t want to participate.

Although somewhat different in design, this new design goes for both Medicare Advantage and Traditional Medicare coverage

[MaryRose416568]

The real question is, does CMS want the providers to keep the patients 'healthier' or to control their 'costs'?  You can call it keeping the elderly 'healthier' to make it look like a reputable program but let's call it what it is.

[JoeH212827]

Welcome to the crowd of abused patients. I haven't been to my doctor since December 2021. Unless I agree to take the Wellness exam, I get no physical. Plus now they cut off my medications that I have had since before Mercy took over St. Johns. I am over 80 years old. There is big money in this thing my Medicare part C provider sent letter offering $100 bonus for those taking it.   In reply to the person saying it is beneficial to my Doctor, My doctor already knows all those answers, if fact when they decided to make it mandatory I refused to answer, he filled it out himself.  My provider charges for 2 visits but you only get one. It is illegal for the wellness visit to be at same time or even same day as a physical. Hence they charge for 2 visits to hide fact it is given WITH physical. You get 1 visit...FRAUD...

[moreorp]

Report this to Dept of Health and human Services and to Medicare.

[GailL1]

Medicare.gov - Annual Wellness Visit Coverage

What’s in it and what’s not - 

Yes, there could be extra stuff done depending upon your health and the medications which have to be monitored by some test in order to continue them.

Medicare Advantage plans are managed care type plans - it saves you from the cost associated with Traditional Medicare IF YOU DON”T BUY A MEDIGAP plan.

[MaryRose416568]

If you read 'Beckers Healthcare newsletter' recently, they are more and more institutions that are dropping Medicare Advantage plans. (They cant stay in business seeing these patients.)

[ss11943859]

I never heard of the wellness visit being mandatory, but I suppose it's a good idea. Doesn't amount to much though. They listen to the heart, look down your throat, look in your ears, that's about it. Some exam !  I made an appt. for a physical exam, expecting blood tests, pap smear, etc. ( first full physical in years). All i got was a wellness exam-again. Dr. said she'd skip the pap smear, because 'women my age rarely get that type of cancer'. Think she skipped everything else, too. Some doctor ! I'm in the market for another medical professional-IF I can find one.

[GailL1]

@CindyV865042

Right, not mandatory but is it informative to your Medical provider?  How better for your doctor to find out about you and keep down medical cost than ask questions and make note of the answers.

It is Preventive Medicine and includes lots of stuff that could have a bearing on your risk factors.  Sounds like you had the HRA - Health Risk Assessment.

These are all the Wellness visits that are either covered by Medicare or not, written as directions to the physicians from CMS - from coding to what is or is not covered by Medicare.  Very informative -

Medicare Learning Network - Annual Wellness Visits Booklet

If it is a joke, perhaps we need to get Medicare to stop paying for them and just do like other medical providers do and give you a form to fill out before your visit - on your own time and nickel.  Problem is, it is for all Medicare beneficiaries and many of them cannot fill out a form by themselves.

Do you not believe in this sort of Preventive Care, i.e. cutting down on the risk before something bad happens whether or not that is getting a person wear a helmet while ridong a bike or getting their blood pressure taken or taking a detailed family or medical history?

[moreorp]

What I don’t believe in is forcing any patient to do anything that don’t WANT to do. For me-if I want help for something, I will ask for it!!

[moreorp]

This is not preventive MEDICINE. Preventive medicine is physical screenings, vaccinations, i.e. - PHYSICAL EXAMS. This AWV feels to me like doctors intruding into personal private lives to “advise” them about how they can live more safely.
I’m 71 years old and I have lived my life as safely as I can or care to and I don’t need someone intruding into my personal home life telling me I need some kind of “counseling”. I probably know more about nutrition, exercise, and quitting smoking than people who would be “counseling”me!!!

This is not medical - it is intrusion into personal private lives that I, among others as I see here, is not welcome.