FPs Report Glitch in Payment for Medicare Wellness Visit

AAFP Intercedes on Members' Behalf

February 09, 2011 04:25 pm Sheri Porter

Last fall, Norman Chenven, M.D., anticipated that, come January, he would see a surge of patients requesting Medicare's new annual wellness visit, and he wasn't disappointed. He was surprised, however, when his Medicare contractor subsequently denied some claims for the visits.

Chenven, a family physician, is founder and CEO of the Austin Regional Clinic in Texas. The 280-physician multispecialty group includes 80 family physicians and 20 internists. On Jan. 3, the first business day of 2011, physicians in the clinic saw more than two dozen patients for Medicare wellness visits.

"This thing is viral in the Medicare population," said Chenven. Although the wellness assessment is not compulsory for Medicare patients, demand is high because the benefit has been highly publicized by CMS as a "free" service, he added.

What the CEO didn't anticipate was a claims processing challenge.

These Medicare Administrative Contractors Are Reprocessing Claims Denied

Chenven said the director of his clinic's central billing office, Lucy Sumner, reported that 25 percent of the annual wellness visits billed between Jan. 3 and Jan. 19 were denied by his Medicare carrier as an uncovered benefit.

According to Cynthia Hughes, C.P.C., an AAFP coding and compliance specialist, in January, she began hearing from AAFP members who said claims submitted to Medicare contractors for Medicare's new annual wellness visit were being rejected.

Hughes did some investigating and found that although the new Medicare benefit -- a provision of the Patient Protection and Affordable Care Act of 2010 -- became available to Medicare beneficiaries on Jan. 1, it was assigned an implementation date of April 4. Thus, some Medicare contractors were not prepared to pay claims for the benefit until the April date.

Specifically, Hughes found that some Part B claims submitted between Jan. 1 and Jan. 20 for the Medicare annual wellness visit, which is covered by new Healthcare Common Procedure Coding System codes G0438 and G0439, were incorrectly denied.

Texas Clinic Prepared for Onslaught

Under the tutelage of founder and CEO Norman Chenven, M.D., and President James Merryman, D.O., the Austin Regional Clinic in Texas gets high marks for preparing its physicians to handle an onslaught of patients requesting Medicare's new annual wellness visit.

"We went through a two-minute drill in December to prepare our physicians for the annual wellness visits," said Chenven. "We prepared and designed a template that captures all of the required elements."

Chenven characterized the new benefit as a patient assessment, and he said it is handled quite differently than a normal annual physical for which physicians are trained. Chenven said all elements of the Medicare annual wellness assessment must be performed and checked off. All documentation -- including the patient portion -- must be signed and dated appropriately.

Anything less could lead to a CMS audit and perhaps charges of fraud and abuse, he noted.

Hughes' discoveries led her to contact CMS to be sure the agency was aware of the problem. On Jan. 26, she sent an e-mail to the appropriate staff person at CMS asking for clarification on when family physicians could expect payment for services rendered.

"Family physician practices are hearing from large numbers of Medicare beneficiaries who have been notified by CMS of their eligibility for this new benefit" that becomes available on Jan. 1, said Hughes in the e-mail. These physicians "must make determinations of whether to provide the service as requested or delay appointments until contractors begin paying claims."

"Practically no family medicine practice can afford to finance these services for a three-month period. Can you please confirm or deny whether these claims will be paid prior to April 4, 2011?" Hughes asked the agency.

Although to date, Hughes has not received a response from CMS, she told AAFP News Now that four of the Medicare contractors who were caught up in the claims processing glitch announced that the error had been corrected and physician claims will be reprocessed.

Hughes stressed that no action is required of physicians who experienced claims denials for the annual wellness visit.

Although Chenven said his Texas clinic has the cash reserves to withstand situations where claims are held, others might not be so lucky. "Obviously, we want to get paid for what we do, but our organization is fine," said Chenven. However, small and solo practices probably wouldn't fare as well, he added.

Small primary care practices -- particularly those that have a high percentage of Medicare patients -- likely would feel a significant financial strain if payment was delayed for months, he said.