Medicare Annual Wellness Visit

[harllee]

I am 66 and am on traditional medicare. In December I wanted to get a pneumonia shot and have my cholesterol checked so I made an appointment with my doctor for a "Medicare Annual Wellness Exam". I specifically asked for the medicare annual wellness exam and was not told I would be billed for anything else. I had blood work done ahead of the visit, got the pneumonia shot and discussed the blood work with the doctor, whole thing took about 15-20 minutes. The doctor's office sends a very large bill to Medicare. Medicare pays for the blood work and the pneumonia shot but refuses to pay anything on the $400 doctor's bill because they say the doctor's office coded the bill as a preventive medical exam rather than an annual wellness visit. The doctors office bills me for the entire $400. I call my doctor's billing department and they tell me they cannot recode the bill because it included some things that are not part of the Medicare Annual Wellness visit, specifically a discussion of allergies. I do have allergies and they are noted on my medical chart but I do not remember any discussion of my allergies with the doctor at this visit and there would be no reason to discuss them with my general physician since I go to a specialist for my allergies.

Anybody else have trouble with getting a Medicare Annual Wellness visit correctly billed? Any advice?

 

[savory]

No advice. But, I was also charged for some things on my last physical which I did not expect. In this case, I just paid. But, something did not feel right about it.

 

[braumeister]

The annual wellness visit really covers very little. Anything beyond the specific items listed will be separately billed.

Yearly "Wellness" visits: If you've had Part B for longer than 12 months, you can get this visit to develop or update a personalized prevention help plan. This plan is designed to help prevent disease and disability based on your current health and risk factors. Your provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,” as part of this visit. Answering these questions can help you and your provider develop a personalized prevention plan to help you stay healthy and get the most out of your visit. It can also include:

• A review of your medical and family history
• Developing or updating a list of current providers and prescriptions
• Height, weight, blood pressure, and other routine measurements
• Detection of any cognitive impairment
• Personalized health advice
• A list of risk factors and treatment options for you
• A screening schedule (like a checklist) for appropriate preventive services. Get details about coverage for screenings, shots, and other preventive services.
• Advance care planning

This visit is covered once every 12 months (11 full months must have passed since the last visit).

 

[kaneohe]

Seems to be a common problem.......my clinic now makes you sign a form acknowledging that you know that a wellness visit is a wellness visit and anything extra will cause additional charges. IMHO, the wellness visit is kind of a joke.......they just want to see you physically, that you are alive and breathing and see how fast you can get up out of the chair, walk to the door, touch the doorknob, and return to chair........and can understand the conversation. Kind of like a marketing program.....FREE annual wellness visit!

The only consolation seems to be that you can combine the 2 purposes into one office visit. Yes, you get the extra charges but at least you save that 2nd trip to doc's office.

 

[HadEnuff]

I am fast approaching the time I have to make some decisions regarding Medicare, as I will be 65 in September.

If one has a Medigap policy, would those "extra" charges be covered under the Midigap?

 

[harllee]

Seems to be a common problem.......my clinic now makes you sign a form acknowledging that you know that a wellness visit is a wellness visit and anything extra will cause additional charges. IMHO, the wellness visit is kind of a joke.......they just want to see you physically, that you are alive and breathing and see how fast you can get up out of the chair, walk to the door, touch the doorknob, and return to chair........and can understand the conversation. Kind of like a marketing program.....FREE annual wellness visit!

The only consolation seems to be that you can combine the 2 purposes into one office visit. Yes, you get the extra charges but at least you save that 2nd trip to doc's office.

But Medicare is paying zero on this bill. I would have been better off going in for some kind of complaint and then medicare would have at least paid something and my supplement would have paid something.

 

[harllee]

I am fast approaching the time I have to make some decisions regarding Medicare, as I will be 65 in September.

If one has a Medigap policy, would those "extra" charges be covered under the Midigap?

I have a Medigap policy but it is paying zero on my annual wellness visit since Medicare rejected it. Medigap pays only if Medicare pays.

 

[kaneohe]

But Medicare is paying zero on this bill. I would have been better off going in for some kind of complaint and then medicare would have at least paid something and my supplement would have paid something.

Something seems wrong in the coding for your visit. If it was coded as wellness visit, then should be no charges. If they charged you extra, then it should be coded as something else and assuming it was medically necessary, all parties should have paid something. I have plan F and never paid a penny for anything but the premiums.

 

[harllee]

Something seems wrong in the coding for your visit. If it was coded as wellness visit, then should be no charges. If they charged you extra, then it should be coded as something else and assuming it was medically necessary, all parties should have paid something. I have plan F and never paid a penny for anything but the premiums.

OP here, yes it was coded incorrectly but so far the billing department refuses to change the code. How do I get the code changed?

 

[braumeister]

I would escalate it up their chain and explain that you will report them for Medicare fraud if they do not correct it.

 

[fritz]

I am 66 and am on traditional medicare. In December I wanted to get a pneumonia shot and have my cholesterol checked so I made an appointment with my doctor for a "Medicare Annual Wellness Exam". I specifically asked for the medicare annual wellness exam and was not told I would be billed for anything else. I had blood work done ahead of the visit, got the pneumonia shot and discussed the blood work with the doctor, whole thing took about 15-20 minutes. The doctor's office sends a very large bill to Medicare. Medicare pays for the blood work and the pneumonia shot but refuses to pay anything on the $400 doctor's bill because they say the doctor's office coded the bill as a preventive medical exam rather than an annual wellness visit. The doctors office bills me for the entire $400. I call my doctor's billing department and they tell me they cannot recode the bill because it included some things that are not part of the Medicare Annual Wellness visit, specifically a discussion of allergies. I do have allergies and they are noted on my medical chart but I do not remember any discussion of my allergies with the doctor at this visit and there would be no reason to discuss them with my general physician since I go to a specialist for my allergies.

Anybody else have trouble with getting a Medicare Annual Wellness visit correctly billed? Any advice?

DW went to her new primary care doctor under the ACA HMO policy. Ran into the same scenario - they finish the wellness/intro exam and they ask the telling question "anything else we should discuss?" If you answer no - you're usually fine. If you answer yes, you most likely will see a billing related to that new discussion that is not normally covered under the wellness/intro visit. They know this, and I told my wife to find another doctor who would handle issues per known guidelines, and not cause uncovered billings like the one we received from her new doctor. You can see by the responses that this is not a rare scenario.

 

[Gotadimple]

The wellness visit is just that. They take your weight and BP, test your memory, and generally will renew medications and review lab results. That's what you get for free.

If you should discuss a specific complaint it is billable as a office visit and consultation.

 

[harllee]

The wellness visit is just that. They take your weight and BP, test your memory, and generally will renew medications and review lab results. That's what you get for free.

If you should discuss a specific complaint it is billable as a office visit and consultation.

OP here, I only got the wellness visit stuff, that is what I asked for and that is all I got. I did not have any specific complaints or questions so I don't understand how they can bill me for anything other than a wellness visit. Is this medicare fraud?

 

[joeea]

Any advice?

Find a new doctor's office that will actually listen to what you tell them and will follow your specific requests.

 

[braumeister]

OP here, I only got the wellness visit stuff, that is what I asked for and that is all I got. I did not have any specific complaints or questions so I don't understand how they can bill me for anything other than a wellness visit. Is this medicare fraud?

What were the codes they billed for? You can look them up online and should be able to see if there is anything you did not receive.

 

[harllee]

What were the codes they billed for? You can look them up online and should be able to see if there is anything you did not receive.

They billed it as a 99397, preventative medicine exam, rather than a G0439, wellness visit. The doctors office claims since he discussed allergies with me (which I do not remember) it turned the whole visit into a 99397, preventative medical exam, which Medicare down not pay. I have appealed this to the higher level of the billing department. If that does not work I will get my doctor personally involved. It is a very large practice associated with a medical school and I am sure he is not involved in billing at all. If that does not work I may file claims for medicare fraud with Medicare and the state SHIP but in that case I will need to find another doctor, which I hate to do because I really like my doctor..

 

[grasshopper]

Go to mymedicare.gov and check the status of your claim look at the MSN.

G0402 - Initial Preventive Physical Examination; Face-To-Face Visit, Services Limited To New Benefic 1 0521 - Clinic visit by member to RHC/FQHC

G0438 - Annual Wellness Visit; Includes A Personalized Prevention Plan Of Service (Pps), Initial Vis

My first visit was G0402 and was paid.

 

[harllee]

Go to mymedicare.gov and check the status of your claim look at the MSN.

G0402 - Initial Preventive Physical Examination; Face-To-Face Visit, Services Limited To New Benefic 1 0521 - Clinic visit by member to RHC/FQHC

G0438 - Annual Wellness Visit; Includes A Personalized Prevention Plan Of Service (Pps), Initial Vis

My first visit was G0402 and was paid.

I have reviewed my account at medicare.gov and talked to a person at Medicare.. It should have been billed as a G0439, annual wellness exam, but instead it was billed as a 99397, preventative medical exam, which Medicare will not pay. I have asked the billing department to send a corrected bill to Medicare with the code G0439 but so far they have refused.

 

[fritz]

I am 66 and am on traditional medicare. In December I wanted to get a pneumonia shot and have my cholesterol checked so I made an appointment with my doctor for a "Medicare Annual Wellness Exam". I specifically asked for the medicare annual wellness exam and was not told I would be billed for anything else. I had blood work done ahead of the visit, got the pneumonia shot and discussed the blood work with the doctor, whole thing took about 15-20 minutes. The doctor's office sends a very large bill to Medicare. Medicare pays for the blood work and the pneumonia shot but refuses to pay anything on the $400 doctor's bill because they say the doctor's office coded the bill as a preventive medical exam rather than an annual wellness visit. The doctors office bills me for the entire $400. I call my doctor's billing department and they tell me they cannot recode the bill because it included some things that are not part of the Medicare Annual Wellness visit, specifically a discussion of allergies. I do have allergies and they are noted on my medical chart but I do not remember any discussion of my allergies with the doctor at this visit and there would be no reason to discuss them with my general physician since I go to a specialist for my allergies.

Anybody else have trouble with getting a Medicare Annual Wellness visit correctly billed? Any advice?

If you are sure that you had no discussion about your allergies during that visit (was it listed on that day's visit chart?), you'll need to talk to the doctor directly and get him/her to have billing correct the medicare filing. The billing office is use to (sometimes) angry people calling about billing disputes, and because of that they are somewhat desensitized to most legitimate billing concerns. Good luck. I'd still consider looking for another doctor's office that does its best to avoid this type of financial pain for its patients.

 

[harllee]

If you are sure that you had no discussion about your allergies during that visit (was it listed on that day's visit chart?), you'll need to talk to the doctor directly and get him/her to have billing correct the medicare filing. The billing office is use to (sometimes) angry people calling about billing disputes, and because of that they are somewhat desensitized to most legitimate billing concerns. Good luck. I'd still consider looking for another doctor's office that does its best to avoid this type of financial pain for its patients.

I really don't remember discussing allergies..at most he may have asked if I was still seeing the allergy doctor which I am. Even if we did have a one sentence conversation about allergies would this mean that it could not be billed as a Medicare wellness exam at all and that I would be stuck with paying the full $400 bill? Could they not just break out a small amount for the allergy discussion (if it even happened) and bill the rest as a wellness exam? I do not mind paying if I really owe something but I had specifically asked for a wellness exam and now they did not bill anything as wellness exam.

 

[fritz]

I really don't remember discussing allergies..at most he may have asked if I was still seeing the allergy doctor which I am. Even if we did have a one sentence conversation about allergies would this mean that it could not be billed as a Medicare wellness exam at all and that I would be stuck with paying the full $400 bill? Could they not just break out a small amount for the allergy discussion (if it even happened) and bill the rest as a wellness exam? I do not mind paying if I really owe something but I had specifically asked for a wellness exam and now they did not bill anything as wellness exam.

I guess it comes down to - does your doctor want to try to keep you around as a patient, or just leave you with paying him/her a $400.00 profit for a few words (maybe even not spoken during the visit). I'd probably give him/her the benefit of the doubt and try to talk to him/her directly. Might result in a reduced or removed billing altogether with some friendly discussion. I'd still move on either way - leaving you owing him/her $400.00 when you specifically asked for a no/cost (covered) wellness visit is way out of line...........

 

[MichaelB]

The doctor may not be aware of this specific situation, the billing coder may be motivated to always bill the highest amounts, and challenging the office may end positively. It certainly can't hurt, especially if you insist on speaking directly with the physician.

 

[grasshopper]

Was this your first year on Medicare and first wellness exam?

The ABC's of AWV

https://www.cms.gov/Outreach-and-Ed...MLNProducts/downloads/AWV_chart_ICN905706.pdf

 

[harllee]

Was this your first year on Medicare and first wellness exam?

The ABC's of AWV

https://www.cms.gov/Outreach-and-Ed...MLNProducts/downloads/AWV_chart_ICN905706.pdf

No, this is my second year on Medicare. Last year (my first year on Medicare) I got the Welcome to Medicare exam with this same doctor, all paid by Medicare, no problem. So I thought I would get the Medicare Annual Wellness exam in the same manner but it has not worked that way.

 

[Bram]

Did Medicare actually DENY the claim for $400? For what reason?
Or, did Medicare “Approve” the service & apply the approved service amount (less 80%) towards your annual deductible? Thus ending up with Medicare paying $0. (I don’t think this is the case, but just want to be clear on this.)

I do understand that your assertion is that you believe the visit was within the parameters of Annual Wellness Exam & should’ve been coverered 100%. In spite of that, it seems that they should’ve paid something on a claim coded “99397, preventative medicine exam”? I would have thought Medicare would’ve paid 80% of the approved amount, after deductible met. Medicare EOBs are unnecessarily complicated, obtuse, & redundant, imho.

I too have been stuck between the insurance not paying because of the way something was coded. I’ve told drs “you must code this as an annual physical” (or whatever language the ins company used) only to have him say, “there is no code for that”. Then I asked the ins co what is the code that should be used? Answer: That is up to the dr! Talk about a merry-go-round & feeling powerless!

Good luck in getting it sorted out!