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Outsourcing Chronic Care Management In 2019 – Associated Benefits And Risks

Medicare has offered reimbursements to physicians for Chronic Care Management services since 2015. But still, providers are struggling with patient engagement, education, efficient processes and regulatory compliance.

CCM provider provides 20 minutes of monthly non-face-to-face care management services for beneficiaries with two or more chronic conditions. It helps in managing their conditions, risk factors, medication adherence, and coordination of care with other providers. To bill for CCM services, practices must offer

24/7 access to care management services
a platform for direct patient-practitioner communication
ability to manage transitions between providers and settings

Why are hospitals outsourcing CCM services?

CCM program is a labor-intensive process. It requires

Recruitment and training certified staff
EHR systems to track care plans
Monitor and document monthly calls
Making staff available to patients 24/7
More office space

In order to avoid these challenges, hospitals are outsourcing CCM services.

Advantages of outsourcing CCM services

New significant revenue stream – A small hospital cannot afford costly EHRs, handle staff-patient management, etc. These aspects are important for chronic care management implementation. Hence they are outsourcing CCM services. The outsourcing agencies specialize in CCM services and take a part of the profit from the practice. It generates a new significant revenue stream for practices who otherwise cannot get Medicare CCM reimbursements.
Saves physician’s time and effort – Outsourcing CCM services overcome the time-intensive CCM challenge for many physicians. Many of them do not have the professional staff bandwidth to provide the continuous chronic care management services. The new CMS initiative of paying doctors for CCM services works well with outsourcing.
Better patient satisfaction– The billing physician creates a specific healthcare plan for his patients. The physician then turns that plan over to the CCM vendor who is responsible for the daily or weekly contact with the patient. The CCM vendor monitors the patient’s progress and provides health coaching according to the physician’s care plan. The vendors must make sure that the patient is adhering to the plan and keep the physician posted. This allows the physician to extend his chronic care management to more patients with the required staff bandwidth.
Improved patient interaction – Outsourced services can combine technology, clinical services, and analytics with minimal efforts from the physician’s end. It results in improved patient interactions between actual office visits, with no impact on their current professional staff.
Increased patient enrollment – Outsourcing CCM will allow the physician to

increase and maximize patient enrollment in the program
improve patient compliance
provide CCM documentation requirements

while minimizing the physician’s workload.

Risks of outsourcing CCM services

1. Risk Management – Outsourcing CCM may sound easy on the front end, but it is very hard to mitigate the risks on the back end. Medicare fraud violations cost up to $10,000 per incident and may even subject the physician to a jail term. Outsourced CCM services make the practice actively and directly responsible for multiple risk factors:

Is the person performing the work appropriately credentialed to work in the state (especially nursing-staffed call centers)? Has the practice taken active steps to confirm this is?
Are all of the services billed for on the claims actually performed? Is the practice actively performing spot checks to ensure same?
Is the practice periodically checking that the documentation they receive for these claims and services is actually legitimate?
Is patient’ privacy taken care of? It is HIPAA-compliant?
Is the practice provided audit logs to protect them if they are audited? How often do they receive audit logs?

Never forget that an outsourced CCM vendor is paid on the volume while you hold 100% of the risk. At a minimum, this creates misaligned incentives and requires the practice’s perpetual and diligent oversight.

2. Profit factor – CCM vendors may take from half up to two-thirds of the CCM reimbursement for complete outsourced CCM service. When the added expenses are taken out of the payment, a practice may get only $7 to $12 per patient. In addition to paying the third party, it also has the labor cost of

Filing the claim
Paying the clearinghouse and the biller
Collecting $8 copay.
At one point, there is no profit from outsourced services

3. Patient’s experience – When a practice outsources the CCM services, the CCM vendor takes care of following up with the patients. Every time a patient gets a call, the person calling for rendering CCM service is unknown to them. The patients are not happy with different people calling them up every month. The vendors will not be fully aware of the patient’s medical history resulting in an average CCM call. The patient will also not feel good about talking to random people every month. Patients become dissatisfied with the outsources CCM services and leave the network.

4. Losing continuity with patients – In outsourced CCM, the practice does not get in touch with their patients regularly. When the patient visits the hospital, the physician will have to go through the previous CCM service history. It is better for the practice to do CCM services rather than give it to a CCM vendor. It affects the practice’s patient network and results in revenue loss.

Outsourced CCM services have a mix of advantages and risks. HealthViewX Chronic Care Management solution supports outsourced CCM as well as CCM services provided directly by the practice. The risk factor associated with outsourcing CCM is minimal in HealthViewX Chronic Care Management software.

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler,

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution has features that suit practices as well as CCM vendors. To know more about our Chronic Care Management solution, schedule a demo with us.

References

http://www.federalcharges.com/medicare-fraud-charges-penalties/

What is Complex Chronic Care Management – All you need to know

Chronic Care Management

The Centers for Medicare & Medicaid Services (CMS) considers Chronic Care Management (CCM) as a crucial part of primary care. Chronic Care Management is non-face-to-face care provided to Medicare patients with two or more chronic conditions. It contributes to better health services to people. In 2015, Medicare started to reimburse a certain amount for the Chronic Care Management services under the Medicare Physician Fee Schedule (PFS).

Service Codes

CPT 99487 – Complex chronic care management services with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation, or functional decline
- Establishment or substantial revision of a comprehensive care plan
- Moderate or high complexity medical decision-making
- 60 minutes of clinical staff time directed by a physician or other qualified care provider, per calendar month
CPT 99489 – Each additional 30 minutes of clinical staff time directed by a physician or other qualified care provider, per calendar month (List separately in addition to code for primary procedure)

Difference Between CCM and Complex CCM

CCM (“non-complex” CCM) and complex CCM services have similar health service elements. They differ in the following aspects,

Amount of clinical staff service time provided
Involvement and work of the billing practitioner
The extent of care planning performed

According to Medicare, “Complex Chronic Care Management services of less than 60 minutes in duration, in a calendar month, are not reported separately. Practitioners must report CPT 99489 in conjunction with CPT 99487. They must not report CPT 99489 for care management services of less than 30 minutes along with the first 60 minutes of Complex Chronic Care Management services during a calendar month.”

Eligibility Criteria for Care Providers

Physicians and the following non-physician practitioners may bill CCM services:

Certified Nurse Midwives
Clinical Nurse Specialists
Nurse Practitioners
Physician Assistants

Patient Eligibility

Medicare provides Chronic Care Management services for patients with multiple (two or more) chronic conditions

Expected to last at least 12 months or until the death of the patient
Places the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

As Chronic Care Management services have reimbursements, physicians must consider administering CCM to the eligible Medicare patients. The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex Chronic Care Management services during a given service period, not both.

Supervision

The Complex CCM codes (CPT 99487, 99489) come under the general supervision according to Medicare PFS. A billing practitioner need not give the health service personally. Any qualified care provider can give the service under the billing practitioner’s overall direction and control. The billing practitioner’s physical presence is not required.

CCM Service Summary

Care providers give a non-complex or complex Chronic Care Management service through the following steps,

Initiating Visit – Medicare requires initiation of CCM services for new patients or patients not seen within one year of commencement of CCM. It is a face-to-face visit with the billing practitioner. It includes an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visits. This initiating visit is not part of the CCM service and is separately billed.
Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology.
Comprehensive Care Plan – A person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment. The care provider must,

Provide the patient and/or caregiver with a copy of the care plan
Ensure the electronic care plan is available and shared timely within and outside the billing practice to people involved in the patient’s care

24/7 Access & Continuity of Care – Provide 24/7 access to physicians or other qualified care providers or clinical staff and continuity of care with a designated member of the care team.
Enhanced Communication Opportunities – Enhanced opportunities for the patient to communicate with the physician through not only telephone access, but also the use of secure messaging, Internet, or other non-face-to-face consultation methods.

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler,

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

HealthViewX Chronic Care Management solution has features that satisfy non-complex and complex CCM services. Medicare reimbursements for Chronic Care Management services increase the profits for community health centers. It also benefits patients with multiple chronic health conditions. To know more about our Chronic Care Management solution, schedule a demo with us.

Remote Care And How Chronic Care Management Simplifies It

Healthcare industry of the US has introduced many technologies to give the best care to all irrespective of their place, accessibility, etc. Remote Care to patients is the latest healthcare technology. It enables monitoring of patients’ health outside conventional clinical settings. This may increase access to care and cut down the healthcare delivery costs. Hospitals offer Telehealth services as a part of Remote Care. This includes,

Virtual Consultation – It is a virtual visit that takes place between the patient and the physician. It takes place through audio or video calls. It is effective for common problems like flu, acne, fever, etc. It reduces the patient’s traveling cost and provides better access to quality care.
Remote Health Monitoring – Patient Health Monitoring is the latest technology in the healthcare industry. Patient physiological data like blood pressure, blood sugar, heart rate, etc can be measured by external devices. It can be a Fitbit, apple watch, etc that can communicate with the system in the hospital. It will help the physician to always keep an eye on their patients’ vitals and prescribe telemedicine and preventive care plans.
Chronic Care Management – Chronic Care Management is non-face-to-face care provided to patients with multiple chronic conditions. Medicare reimburses a certain amount for the Chronic Care Management services given by the hospital. Chronic Care Management is most administered through audio calls.

As Chronic Care Management services have reimbursements, physicians must consider administering CCM to the eligible patients. Medicare provides Chronic Care Management services for patients with multiple (two or more) chronic conditions

Expected to last at least 12 months or until the death of the patient.
Places the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.

CCM Service Summary

The following are steps through which a Chronic Care Management service is furnished,

Initiating Visit – Initiation during an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE) or face-to-face E/M visit for new patients or patients not seen within one year prior to the commencement of Chronic Care Management services.
Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications, and medication allergies using certified EHR technology.
24/7 Access & Continuity of Care – Provide 24/7 access to physicians or other qualified healthcare professionals or clinical staff and continuity of care with a designated member of the care team.
Comprehensive Care Plan – Creation, revision, and/or monitoring of an electronic person-centered care plan.
Enhanced Communication Opportunities – Enhanced opportunities for the patient to communicate with the physician through not only telephone access, but also the use of secure messaging, Internet, or other non-face-to-face consultation methods.

Eligibility Criteria for Physicians

Physicians and the following non-physician practitioners may bill CCM services:

Certified Nurse Midwives
Clinical Nurse Specialists
Nurse Practitioners
Physician Assistants

HealthViewX Chronic Care Management solution features

HealthViewX Chronic Care Management solution has the following features that make the process simpler,

Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
Automated call log feature – After a patient call, care plan creation or any action related to Chronic Care Management services, call logs are added to the patient. It reduces the physician’s manual effort is logging the call logs.
Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture from the revenue perspective.
Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the reimbursements.
HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. All patient-related documents are managed securely.

HealthViewX Chronic Care Management solution is on par with the current requirements. Remote care is the easiest and the cheapest way to treat your patients. Medicare provides reimbursements for Chronic Care Management which makes it the best way to give care to patients from the remote. To know more about our Chronic Care Management solution, schedule a demo with us.

Seven Mistakes To Be Avoided In A Patient Referral Network

Referral Networks of healthcare play a crucial role in determining the hospital’s income, patient stability, and information security. It is essential for a practice to build a strong referral network of health providers from the beginning. It requires a strong provider base to strengthen a patient referral network. Once the practice establishes a patient referral network, they have to maintain it. There are few mistakes that every practice makes and are not aware of how they lose their referrals. The following are few mistakes that can affect patient referral networks,

Ignoring Patient Satisfaction – Patient satisfaction is the determining factor of a hospital’s repute. During the referral process, the patients interact with the receiving physician. So patient experience of the referral has a direct impact on the hospital’s patient referral network. In many cases, the physicians are unaware of how the referral process impacts the patient. When the receiving physician finds the referral information incomplete, the physician will make the patient repeat the diagnosis. This affects the patient’s experience. The patient will also not like to bridge the gap between the referring and the receiving physicians. When the patient is dissatisfied, he/she leaves the practice resulting in patient leakage. A Referral Management software that can easily communicate between the referring and receiving physicians will improve the patient’s experience. Surveys and feedback forms keep the practice informed of the patient’s experience. The physicians must handle patients better and make them feel good during the referral process.
Partnering with bad network physicians – Having health partners with bad repute in a patient referral network is the biggest mistake. If the practice is not selective in choosing the physicians, it is bound to witness worst patient experiences. The practice should not sign any physician just because they have good credentials. Even a good physician may not meet the referral requirements. The hospital must take time to analyze the physician and study the provider’s network before signing them. Choosing good health partners is a strategic decision and should make it considering the future well-being of the practice. If the practice is looking for a long-term partnership then should find a stable health partner. In the age of technology, the practice must choose a physician who complies with the EHR/ Referral Management software used. EHR or Referral Management software compatibility issues greatly influence patient referral networks.
Poor communication – Communication is everything in a referral process. It lays the foundation for patient’s experience. As a part of medical care rules, hospitals should have protocol norms for communicating with patients. The practice should train their staff and should check the same regularly. This will make sure that when the practice refers their patients out, all the essential information moves along with them. This will give the patients better understanding of what to expect and what their responsibilities are. The practice must make sure to spend quality time with the patients for their doubts and queries. Patients expect the physicians to communicate smoothly and flawlessly. Living up to the expectations of the patients make the practice run smoothly.
Neglecting measurements – Staying aware of general patient satisfaction may not be enough. The practice must adopt more formal methods of evaluating the health of the network. The practice can get a high-level view of what’s going on through surveys, feedbacks, software etc. These tools can be used to get patient opinions, evaluate the smoothness and timeliness of transitions. It can also say how well the practice has established patient expectations around referrals and how well they’re being met. Surveys can be anything as simple as a form of feedback options integrated into the patient portal solution. The practice must make sure that the surveys cover topics like coordination, access, and quality of care along with appointment experience. Measurement at this level may require a dedicated staff member, or at the very least, making the required duties a formal part of an employee’s job description. Once the practice has a clear picture of what’s going on, it’s time to improve. The practice can use the information gained to highlight specific areas of improvement. It improves future training and protocol standards.
Neglecting long-term growth – The practice should have a solid business strategy. The American Academy Of Orthopedic Surgeons proposed a ten step process. It helps doctors in having a strategic approach towards the growth of the practice. The process involves market evaluations, budget creation, strategic plans development, marketing plan, new reimbursement model preparation, etc. Business development is the backbone of a strong patient referral network. Once the practice establishes a patient referral network, they must begin adding more doctors and professionals with whom they are comfortable. This will optimize the processes and standards already in place.
Careless about security breaches – One of the few downsides of a well-connected patient referral network is increased exposure to data breaches. Since 2009, 15 million patients’ Personal Health Information has been exposed. A practice should protect their patients’ valuable information. Hiring a professional to audit the practice’s internet breach can help. Audits detect unauthorized access to patient information, curb inappropriate accesses and track misuse of PHI. A practice can consider partnering with other network members. It cuts down the cost of bringing in outside consultants and solutions. The practice must keep all personnel properly trained on HIPAA guidelines.
Using outdated technology – The increase in the number of referrals on a daily basis makes it very tedious and difficult for the existing process and system to manage them. The most commonly used system of referrals being fax and this method of sending / receiving referrals is time-consuming and prone to errors. Communication with the PCP’s and the patients on follow-ups and sharing of the results is a cumbersome process which impacts the overall satisfaction of the both. Considering the complexity of referral system, an effective Referral Management Software is the need of the hour.

HealthViewX Referral Management solution features

HealthViewX Patient Referral Management solution has features that best suit a hospitals’ Referral Management System.

Seamless communication – HealthViewX solution has an audio calling and messaging features. It enables secure and faster communication among the referring physicians, receiving physicians and patients.
HIPAA compliant data security – The solution is HIPAA-compliant and offers secure data exchange. It supports almost all formats of files that can b sent and received during any time of referral process. It also keeps the patient documents safe.
Referral history – The timeline view provides the history and current status of the referral. A status helps in knowing how far the referral has progressed. It acts as a channel of communication between referring and receiving physicians.
Data Analytics – A comprehensive dashboard helps to track the number of referrals in the queue and shows the number of referrals in different statuses. This helps in knowing how fast the referrals are getting closed.
Report Consolidation – The data regarding the referrals and timeline view can be printed as a report anytime in pdf/excel form.
Invariant referral process – HealthViewX Patient Referral Management solution can integrate with EMR/EHR and can write data of referral into any system if required. It is almost zero deviation from the current workflow a practice is using.

With HealthViewX Patient Referral Management solution in place, physicians never make a mistake in the referral process. Managing a referral life cycle is very easy. A 30-minute demo with our team will help you know how effective our solution is in tracking and managing the referral process. To know more schedule a demo with us.

How Can An Open Patient Referral Loop Hamper Your Network?

The increasing complexity of patient referrals in healthcare

Patient referrals are increasing in number every day. Health Systems and Hospitals which send out numerous medical referrals find it difficult to track and close a patient referral loop on time. What factors prevent the referral coordinators, operations managers, physicians or care providers from closing the patients’ referral loops?

Prior Authorization – The referral coordinator does the insurance pre-authorization for the patient referrals in healthcare. Considering that one out of every three patients is referred to a specialist, it is difficult to do prior authorization. This makes patient referral system time-consuming and affects referral loop closure.
Finding the right specialist/imaging center – The referring provider must choose the right specialist or imaging center that will suit the patient best. He/She should send the referral to a reliable provider who will give the best care and give regular updates. The referring provider must also consider a provider who covers the patient’s insurance before initiating the referral. If the referring provider fails to do this, open patient referral loop becomes imminent.
No updates on the referral progress – The receiving provider fails to update the progress of the referral. 25% to 50% of referring physicians do not know if their patients actually visit the specialist or imaging center. As many patient referrals are initiated on a daily basis, tracking it manually is difficult for the referring provider. This ultimately results in open patient referral loop.
Inadequate referral information – The receiving providers usually have a tough time processing referrals with incomplete information. 70% of the specialists rate the patient referral information from the referring providers as poor. This affects the patient referral lifecycle.
Outdated referral workflow – The current referral workflow is outdated. The providers find it difficult to cope up with the increasing patient referrals in healthcare. On an average, a referring provider spends half an hour to one hour per referral and even more time in following up. Outdated referral technology affects the referral loop closure.

Close a referral loop in healthcare with the HealthViewX Patient Referral System

Information Technology enables patient referral workflow automation. HealthViewX Patient Referral Management System simplifies the process and closes the referral loop on time.

The Primary Care Provider (PCP) identifies the need for a referral and initiates the same through the EHR system.
The referral coordination team then validates the referral and does the insurance pre-authorization with the help of HealthViewX solution.
The Intelligent Provider Smart Search feature of HealthViewX Patient Referral Management System helps in finding the right specialist or imaging center easily.
The referral coordination team then sends the referral with the necessary documents to the relevant specialist or imaging center through the HealthViewX platform.
The receiving provider gets notified about the referral and can schedule appointments with the patient.
The patient and the receiving provider get reminders of the appointments thus reducing no-show rates.
The referring provider is also notified about the status of the referral and how it is progressing. HealthViewX timeline view makes tracking and managing the referral lifecycle easier.
HealthViewX tracks and sends reminders to the receiving provider to update the diagnosis, treatment recommendations, care plans in the referral.
HealthViewX makes it easy for the referring provider by automatically updating this information back to the EHR system.
Thus the HealthViewX solution closes the referral loop on time and helps in easy monitoring of the same.

Features and Functionalities

Referral workflow automation reduces the time and manual effort spent on a referral. Thus HealthViewX solution improves the efficiency of the process.
Patient coordination framework achieved through the patient application that helps in managing appointments and log data for the care plans prescribed by the provider.
Automated insurance pre-authorization reduces the work of the referral coordination team and makes the process simple.
Intelligent Provider Search feature helps in finding the right specialist or imaging center in no time.
Referral timeline view and communication enables easy flow of information between the referring and the receiving ends.
Scheduler integration gives timely reminders and notifications to the patients and the providers about appointments, lab tests, etc.
Referral insights and analytics gives the PCPs concrete data of how many referrals were converted to an appointment by a specialty care or an imaging center. It will help in analyzing who responds quickly and to whom the PCP can direct future referrals.

Benefits of closing the patient referral loop in the healthcare industry

Increased Medicare reimbursements – Medicare considers closing medical referral loop as a benchmark for giving reimbursements. Closed medical referral loops increase the opportunities for Medicare reimbursements for referral marketing.
Streamline referral management – With HealthViewX Patient Referral System in place, the referral workflow is automated and streamlined.
Improved patient care – Reduced waiting time gives patient satisfaction thereby improving the care quality.
Increased productivity – Reduced operational time improves the efficiency of the patient referral system.

HealthViewX Patient Referral Management application helps in closing the referral loop and increases the revenue for the practice. To know more about HealthViewX solution, schedule a demo with us. Our patient referral management experts will guide you through our HIPAA-compliant solution.

How Can Physicians Manage Patients’ Annual Wellness Visit better?

What is AWV?

In the year 2011, the Center for Medicare and Medicaid Services (CMS) introduced the Annual Wellness Visit (AWV). An AWV is a yearly appointment of the patient with the physician funded by the American Affordable Care Act. It is very different from an Annual Physical Exam and is more of an educational visit than a diagnostic one. During this visit, the physician formulates a preventive plan for the patient for the coming year. This plan can help in preventing illness based on current health and risk factors.

Eligibility Criteria

Medicare provides Personalized Prevention Plan Services (PPPS) under the wellness plan for beneficiaries who:

Are no longer within 12 months after the effective date of their first Medicare Part B coverage period
Have not received an Initial Preventive Physical Examination (IPPE) or Medicare yearly wellness visit within the past 12 months

The following medical practitioners are eligible for providing Medicare yearly wellness visit services to patients:

Physician (a doctor of medicine or osteopathy)
Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)
Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioners), or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy)

Medicare Wellness checklist

Initial Annual Wellness Visit – This is applicable the first time a beneficiary receives an Annual Wellness Visit. It includes the following components:

Acquire Beneficiary Information: The physician assesses the health risk factors of the patient. It includes analyzing patient self-reported information, demographic data, daily activities, etc. He/She collects data from the list of physicians who regularly treat the patient. The physician reviews the beneficiary’s medical and social history, completely studies the patient’s potential risk factors, mood disorders, functional ability and level of safety.

Begin Assessment: The physician begins the assessment by measuring the patient’s vitals. He/She identifies the patient’s illness through direct observation, medical history, concerns raised by family members, friends, caretakers, etc.

Counsel Beneficiary Action: The physician establishes a written screening schedule for the beneficiary, such as an appropriate checklist for the next 5 to 10 years, etc. He/She furnishes personalized health advice to the beneficiary and generates appropriate referrals to specialist clinics or imaging centers. The physician gives advance care planning at the discretion of the beneficiary.

The subsequent Medicare yearly wellness visits include the above components and will be updated on the later patient visits.

Billing Codes for Medicare Yearly Wellness Visit

G0438	$117	Annual wellness visit which includes a personalized prevention plan of service (PPS) and the first visit
G0439	$173	Annual wellness visit which includes a personalized prevention plan of service (PPS) and the subsequent visits

Tips for physicians to benefit from Annual Wellness Visit

Managing patients – All Medicare Part B patients are eligible for Wellness Plan services. It is necessary for the practice to find the right patients who would benefit from this service. The physicians must give the patients a clear idea of how Medicare Wellness Program process works, what they can expect from the service, etc. The practice must make the patients aware of the reimbursements and the additional charges they may incur depending on their insurance coverage.
Developing protocols for schedules – A Medicare Wellness Program takes a great deal of both staff and physician resources to give the service. It is better for a practice to take some time to decide how these appointments best fit into their existing schedule. Creating a scheduling protocol will save more time and frustration. For example, how many days in a week, the practice can schedule these appointments, what tool for tracking the Medicare Wellness Program services, patient records, reimbursement rates, etc.
Pre-visit planning – The practice must verify not only the patient’s Medicare Part B effective date but also whether the patient has received a Wellness Plan from any physician in the last 11 months. Otherwise, Medicare may deny the service, leaving the patient with an unexpected bill. The practice must do the same verification for other preventive services that patients receive along with the Medicare Yearly Wellness Visit. It is ideal to have the staff note the last date of these preventive services on a Medicare Yearly Wellness Visit documentation form in advance of the visit. This will help in determining which preventive services are needed and whether the patient is eligible to have these paid for by Medicare. A pre-visit history can also find whether the patient needs any laboratory tests such as the cardiovascular scans, diabetes screening blood tests, etc. These should be completed prior to the Medicare Yearly Wellness Visit to allow discussion of its results at the visit.
Planning for effective follow-up care – The physician should analyze the patient’s risk factors and problems accurately during the Medicare Wellness Program. The physician must generate a care plan for the patient considering these factors. It is necessary to develop a preventive service plan and a general checklist for the next ten years. The physicians should follow-up the same on the patient’s subsequent Medicare Yearly Wellness Visits.
Getting complete reimbursements – The last step in providing the Medicare Yearly Wellness Program is to get paid the service rendered. AWV attracts the physicians’ attention because of the reimbursements offered by Medicare. The practice must keep up a clear documentation to make the process hassle-free.

These practices simplify the Medicare Wellness Program process thereby improving the efficiency of the practice. The HealthViewX solution eases the AWV workflow for the practice. With HealthViewX solution, there is no chance of losing the reimbursements. To know more about HealthViewX solution, schedule a demo with us.