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Medicare Guidelines

Do you perform annual wellness visits with all Medicare patients? If not, your practice may face cuts in reimbursements and patient referrals.

Annual Wellness Visits

In 2011, the Centers for Medicare and Medicaid (CMS) released new guidelines and a new benefit for seniors to address annual care. This new Annual Wellness Visit (AWV) was designed to provide a wellness check for Medicare patients that previously had to pay out-of-pocket for a physical exam. The main goal of the AWV is to reduce the likelihood or the duration of serious problems for a patient in the future. In addition, Medicare waives both the coinsurance and copayment and the Medicare Part B deductible for the AWV.

With the release of these new guidelines, the Routine Physical Examination (RPE) is no longer covered by Medicare and is 100 percent out-of-pocket for the patient. The only exception to the statute is if the RPE is performed in relation to diagnosis or treatment of a specific illness, symptom, complaint, or injury.

As part of the AWV, the patient first receives an Initial Preventative Physical Examination (IPPE). This IPPE should be completed sometime in the first 12 months of Medicare coverage. Once the patient is at least 12 months beyond the eligibility date for their first Medicare Part B benefit period, they are eligible for an Annual Wellness Visit each year, provided that it has been at least 12 months since their IPPE or their last AWV.

The benefits of providing AWV’s are:

  • An opportunity to coordinate care and proactively address whole patient care
  • An AWV can be reimbursed in addition to the standard office visit
  • Provides an opportunity to discuss advanced care planning and make any necessary referrals to community-based resources
  • Patients generally like this type of appointment and it is a time to further engage with patients and encourage constancy of health care choices (including the provider)
  • An opportunity for open exchange of information. The patient may disclose other problems that could require additional studies and follow-up care.

MACRA and MIPS Scores

On November 1, 2018, CMS released revisions to payment policies under the Medicare Part B physician fee schedule for the Quality Payment Program (QPP) for the calendar year 2019. At that time, the Medicare Access and CHIP Re-authorization Act of 2015 (MACRA) repealed the Medicare Part B Sustainable Growth Rate (SGR) reimbursement formula and replaced it with the QPP. The QPP consists of two major tracts including the Merit-based Incentive Payment System (MIPS) and the Alternative Payment Models (APMs).

Merit-based Incentive Payment System

The Merit-based Incentive Payment System (MIPS) is designed to be the major catalyst towards transforming the healthcare industry from fee-for-service to pay-for-value. Every year eligible Medicare Part B clinicians are scored on a 100-point MIPS performance scale.

Financial Impact

Plain and simple, the MIPS scoring can affect your bottom line. The Part B service payments are adjusted up or down based upon your MIPS performance score. These adjustments are applied to the Medicare payment for every Part B service billed by you for two years after that performance year’s rating. However, under MACRA, CMS is allowed to make the MIPS transition more gradual, with certain program values to vary between 10% and 30%. These thresholds will gradually increase each year through 2022.

CMS, under the authority MACRA, made it easier to avoid penalties in years 2017 and 2018. However, to prepare providers to reach the requirements by the 2022 performance year, CMS is significantly increasing the difficulty of the program in 2019 such that the estimated maximum incentive is 4.69%, a 150% increase from that of 2017.

Professional Reputation

In early 2019, MIPS scores (from cy 2017) of more than half-a-million clinicians will be published by CMS. This public reporting component to MIPS can impact a clinician’s professional reputation. Third-party consumer rating sites will also have access to these ratings. They will be able to publish a peer comparison of providers on a 5-star rating scale. This can be done for each MIPS quality measure.

As consumers spend more money out-of-pocket for their healthcare, they search online for reviews on physicians. They look for physician ratings and practice reviews. A study published in the Journal of Medical Internet Research found that more than half the responding medical providers that were surveyed, used online ratings to determine the area(s) in need of improvement related patient care.

The most widely implemented quality measures were those related to communication with patients. So, even though financial implications might change yearly, a tarnished internet reputation could take years to improve. This is particularly important, as these scores follow the provider even if they move to another practice or organization.

​How AWV+ Works for Physicians

Bird Dog Pharma’s AWV+ allows you to​ conveniently provide your patients annual wellness visits and preventive care plans. Our web-based program goes one step further by identifying additional ancillary services like:

  • Basic and Advanced Laboratory Panels
  • Toxicology screening
  • Pharmacogenomics
  • Allergy Testing
  • ​ANS/ABI Testing
  • ​Vestibular Testing
  • ​Cancer Screening

How Does AWV+ Benefit Your Patients?

First and foremost, an Annual Wellness Visit is free for your patients. The ​​Affordable Healthcare Act requires that ​an AWV is covered 100% with no co-pay or deductible. Medicare also waives both the coinsurance or copayment and the Medicare Part B deductible for the AWV.

It is easy and convenient for your patients. The patient is given an iPad after they check in and are asked to answer questions while they wait to see their clinician. There are no additional appointments or office visits necessary because it can be completed at a regularly scheduled appointment.

Finally, each participant receives a Personal Report immediately after completing the ​assessment. This easy-to-read, color-coded report is organized into ​8 key areas. It provides an Overall Wellness Score and briefly describes the impact of each risk factor on their health.

Our ​health risk assessment is designed to help you improve your patient’s health outcome. It focuses on emergent and existing needs, identifying their risk factors for chronic disease and injury. This is also great for patient education, in that you can put it in your patient’s hand. It goes home with them as a reference tool and is a reminder of goals and the plan of care that has been discussed.

How Does AWV+ Benefit Your Practice?

Our AWV+ program uses branching logic to identify health risk factors based on the individual’s lifestyle habits and measures his or her readiness to change. This helps you focus interventions and programs on areas where they are most likely to have a positive impact. The areas that are covered include:

  • Personal ​Medical History
  • ​Family History
  • ​Doctors Office & ER Visits
  • ​Fall Prevention
  • ​Weight Management
  • Depression
  • Fitness & ​Nutrition
  • ​Cognitive Impairment
  • ​Substance Abuse
  • Mental Health
  • ​Functional Ability ​& Safety
  • Daily Habits

You have 24/7 access to raw data on all participants and groups in your program via a detail list. Administrators and analysts can also perform in-depth analysis and customize their own reports.

This program offered by Bird Dog Pharma is 100% CMS compliant for data capture and patient counseling and is fully auditable. In addition to billing the AWV and E/M codes, our program will identify additional ​ancillary services.

We know that your time is valuable, so the questions can be answered by the patient in 10-15 minutes while they wait to be seen. Once the questions are completed, you have the ability to generate an easy-to-read, color-coded report for you and the patient. One report is retained in the patient chart for future reference and the other report goes home with the patient.

The information that is generated by this report can help you close the care gap by identifying patient risk factors and developing a preventive plan. It will also increase your ability to score higher on the 100-point MIPS performance scale.