In a recent blog, we described preventive services as "The Missing Link to Wellness." Research backs this claim up, showing that preventive services have the potential to dramatically reduce healthcare spending, improve economic output by billions of dollars, and save tens of thousands of lives. To help you better appreciate why preventive services should be offered by your practice and what to know before proceeding with adding such an offering, here is some of the essential information to understand about the preventive services Medicare covers.
Want to learn more about providing and getting paid for preventive services? Check out our detailed guide!
1. Definition of Preventive Services
In the event that the concept of preventive services is new to you, let's explain the term before we dive into my details. Preventive services on Healthcare.gov is defined as follows: "Routine healthcare that includes screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems."
2. What Preventive Services Medicare Covers
Medicare Part B covers a wide range of preventive services. Among the most common provided to patients by practices are as follows (listed in alphabetical order):
- Advance Care Planning*
- Alcohol Misuse Screening & Counseling
- Annual Wellness Visit (AWV)
- Counseling to Prevent Tobacco Use
- Depression Screening
- Intensive Behavioral Therapy (IBT) for Cardiovascular Disease
- IBT for Obesity
- Lung Cancer Screening Counseling and Annual Screening for Lung Cancer With Low Dose Computed Tomography
* While advance care planning is not technically a preventive service, it is often spoken about as if it is such a service and is treated as a preventive service in reimbursement policy.
3. Role of the Medicare Annual Wellness Visit
Generally speaking, the Medicare annual wellness visit is a yearly appointment where a patient meets with a clinical staff member (with minimal provider interaction, when needed) to develop or update a personalized prevention plan. This plan is based on a patient's current health and risk factors and is designed to help prevent disease and disability.
What does the Medicare AWV have to do with preventive services? Besides being considered a preventive service itself, it is also an opportunity for — the preventive services identified above and others to be provided, recommended, and/or scheduled. It is a requirement of the AWV to create a future schedule of preventive services for the patient, which makes furnishing needed preventive services in the same encounter an added convenience for patients and providers. This convenience is important for the patient and practice as preventive services help identify diseases early (when treatment works best) while also making the AWV even more financially lucrative for providers (more on this below).
4. Coverage of Medicare Preventive Services
Many preventive services are covered in full by Medicare Part B, meaning Medicare beneficiaries will have no out-of-pocket expenses (co-payment or deductible) owed to the doctor for their provision. Fully covered preventive services include those listed above (in #2) as well as the likes of diabetes screening (up to twice per year for those patients at high risk of diabetes) and hepatitis C screening test (for those patients at high risk). Some preventive services that are likely to require cost-sharing by the beneficiary include a diagnostic mammogram, digital rectal exam for prostate cancer, and glaucoma test.
Patients may pay more out of pocket if they see providers who do not accept the preventive services assignment and/or if they are enrolled in a Medicare health plan or have other insurance. Patients will also pay more if they exceed the covered frequency of a preventive service (e.g., more than one annual depression screening, more than one annual alcohol misuse screening).
5. Reimbursement for Preventive Services From Medicare
As previously noted, furnishing the Medicare annual wellness visit is financially worthwhile, with practices receiving roughly $170 per initial AWV and $135 per subsequent AWV. This figure increases as appropriate preventive services are provided in conjunction with the AWV. Taking a conservative approach to frequency of eligibility, Medicare patients who receive a full suite of preventive services could increase practice revenue by more than $360 annually per patient. If 50 patients receive the full suite, that translates to about $18,000 in annual reimbursement associated with the delivery in preventive services. In many cases these services can be completed in a single visit.
The following is a breakdown of the 2020 average reimbursement for preventive services commonly performed with the Medicare annual wellness visit, as obtained from the Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule:
- Advance Care Planning — $86
- Annual Depression Screening — $18
- Annual Alcohol Abuse Screening — $19
- Alcohol Counseling — $26
- Smoking Cessation Counseling — $16
- Cardiovascular Risk Counseling — $26
- Obesity Counseling — $26
To help ensure you get paid appropriately for furnishing preventive services, read this blog on Medicare AWV and preventive services billing codes.
6. Avoiding Denials for Preventive Services
Besides properly coding Medicare preventive services, practices must ensure they determine the last date that their patients received preventive services to verify whether patients are eligible to receive the next service and the service will not be denied due to frequency edits. To perform this verification, practices essentially have two options:
- Automated verification via the Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System, also known as HETS. Providers can access this system and use it as their primary Medicare information source for patient eligibility and liability. However, doing so can be difficult and expensive as it requires either the development or acquisition of a tool needed to meet access requirements. Instead, many practices choose instead to partner with a vendor (such as Prevounce) that has completed the steps required to support electronic eligibility transactions and office automation.
- Manual verification, which is typically completed via phone call, clearinghouse, or Medicare administrative contractor (MAC) portal. The downside of manual verification is that it's more time-consuming than automated verification. It will become even more time-consuming if challenges are encountered with initial verification efforts, thus requiring staff to follow up until verification is determined.
7. The Process for Preventive Services to be Chosen as Medicare Benefits
The population health and health data surrounding the effectiveness and benefits of preventive services are constantly reviewed. As such, there are processes in place for the addition of preventive services as covered Medicare benefits. CMS has the ability to add coverage through the National Coverage Determination process if the service meets the following criteria: 1) reasonable and necessary for the prevention or early detection of illness or disability; 2) recommended with a grade of A or B by the U.S. Preventive Services Task Force; and 3) appropriate for individuals entitled to benefits under Part A or enrolled under Medicare Part B.
CMS can also add additional preventive services through its statutory and regulatory authority. Private health insurance companies often follow Medicare’s lead when it comes to covering preventive services and are even legally required to cover many services that the U.S. Preventative Services Task Force finds particularly beneficial for patients and the health system as a whole.
8. Helping Patients Stay on Track
For patients who require many preventive services, and even those who only require a few, remembering when to schedule the next service can prove difficult. It can become even more challenging when the timing of one preventive service is different than another (e.g., annual versus monthly). While technology can help by providing electronic reminders to patients, Medicare's downloadable "Are You Up-To-Date on Your Preventive Services?" checklist can be a helpful resource to provide to patients. The National Council on Aging has its own Medicare preventive services checklist that may help patients and your practice.
Prevounce Simplifies the Delivery of Preventive Services to Medicare Beneficiaries
While delivering preventive services can seem complex, especially when you dive deeper into documentation, coding, and billing requirements, the Prevounce platform makes it even easier than you may imagine. We invite you to learn more about Prevounce and why our intuitive platform is the solution of choice for a growing number of practices nationwide looking to deliver more efficient preventive services that improve patient health and the bottom line.