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The Medicare Annual Wellness Visit – Getting to Benchmark is a Win-Win

What if you began receiving information that described new benefits under your insurance plan that are “free to you.” For example, you receive notice that your insurance company wants you to have an annual wellness visit that focuses on health promotion and disease detection and, by the way, no co-pay. In fact, no financial obligation on your part at all. It sounds too good to be true however, it’s not! That is exactly what Medicare is telling their patients when they become eligible for Medicare.

So, if Medicare is offering this phenomenal Annual Wellness Visit (AWV) benefit (which it has since 2011), then why are only about 20% of Medicare patients taking advantage of the opportunity? This article discusses some of those reasons and what physician practices can do to help improve the penetration rate.

The Win-Win

First, let us agree that the Medicare AWV is a win-win; that is, it is a win for the patient insomuch as they can get professional oversight of their personal health promotion and disease detection by their own primary care provider. Second, it is a win for the providers insomuch as they can dedicate at least one visit per year on wellness (proactive) versus a focus on sickness (reactive) and the payment they receive for the service is outstanding. According to a study by the Medical Group Management Association (MGMA), “In a practice with a Medicare population of approximately 750 patients per provider, the Initial AWV could result in $129,750 of additional revenue for the first year and $87,750 each additional year per provider, demonstrating the opportunity to generate steady income.” There is also additional revenue for hospitals (lab, radiology, etc.) who own/manage physician practices.

So why don’t practices have at least 50% of their Medicare patients consistently participating in this offering?

The Opportunities

  1. For some Medicare patients, the offering is “too good to be true.” There are a number of advertisements to Medicare patients which have caused the patients to be skeptical over the years. So even when their own providers try to help patients get on board, the patients are skeptical about what they will have to pay. It becomes difficult for the patients to unravel the wellness visit from a normal office visit.
  2. Some providers think they are already doing the visit. With a deeper look, however, it is often uncovered that they do, in fact, have some elements of the wellness services inculcated into their visits. Unfortunately, they only have skimmed the service on the screening and diagnostic services that Medicare actually offers.
  3. Providers may feel they do not have the capacity (human resources and space) to integrate the AWV into their practice.
  4. Many providers have not leveraged their electronic health record to make documenting and billing the AWV “user-friendly.”


  1. Practices have to make a commitment to a disciplined approach to the AWV. Then, they must convince their Medicare patients of the benefits. Letters or recorded calls from their provider is a good start. Then, the practice needs a process to contact the patients to schedule (and reschedule) the appointments.
  2. The AWV must be singled out as a visit that stands on its own. There are specific requirements for the AWV. They are not difficult but when practices try to consistently mix a “well” visit with a “sick” visit, the visit becomes diluted and the criteria to bill the AWV may not be met.
  3. The industry is moving toward value-based purchasing and population management. The AWV fits nicely into these concepts. Evaluate both space and human resources and make a plan to integrate these visits. Examine hours of operations, potential synergies between practices, the sharing of resources, etc. Also, understand that a physician does not have to be the one to conduct the AWV.
  4. The electronic health record should be configured to trigger the next AWV appointment. It should also be configured to trigger services that are included in the AWV program. For example, suppose you have a patient that joins your panel. She just turned 65 and has never had a mammogram. The electronic health record should trigger the provider to consider ordering the mammogram at the AWV.


The AWV is a benefit that can add value, first and foremost, to patients. There is no co-pay for the AWV and the visit is designed to promote health and detect disease/issues early. Second, the payment to providers for the visit and the triggered services (mammogram, colorectal screening, diabetes screening and training, vaccines….the list goes on) is favorable. Providers should look at how many AWV services (G0438 and G0439) were billed out in the last 12 months and compare that to the number of Medicare patients on their panel. If the penetration rate is less than 50%, it is time to take steps to improve!

If you have questions about how to put these suggestions into practice, please contact your local Blue & Co. advisor

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