MassCare Announces New Client Implementation at Internal Medicine of Milford, P.C.

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ST. PETERSBURG, FLA. AND MILFORD, CONN. APRIL 09, 2019

MassCare, LLC announced a successful launch and implementation of its AWV and CCM solutions with Internal Medicine of Milford, P.C. (IMM), an innovative healthcare provider of Patient Centered Care located in Milford, Connecticut.

The selection of MassCare as IMM’s AWV & CCM program provider came after an internal evaluation of the most efficient and cost-effective way to deliver these two critical Population Health Management programs being promoted by the Centers for Medicare and Medicaid Services (CMS).

MassCare has grown to be one of the most respected and admired AWV & CCM program providers in the country. Built upon reputation, MassCare is a leader in bringing both staff and technology solutions to the healthcare industry, offering customers a unique array of technology and services unavailable elsewhere.

“We initially launched both AWV and CCM programs using internal staff resources and although successful, we recognized that the programs had room for advancement in terms of patient saturation, comprehensiveness and efficiencies.” said Lorri Brown-Ominsky IMM’s Practice Administrator. “MassCare differentiated itself on a number of levels, including company values, approach of leveraging clinical pharmacists, turn-key program management, streamlined implementation and clinical excellence." Brown-Ominsky continued, “We’ve always strived to be the most innovative clinic in the greater Milford area by providing proactive care to our patients, and MassCare’s team and approach align well with our organizational culture.”

IMM’s Dr. Paris Spanolios, M.D. stated, “I sit on the board of directors for Community Medical Group, which is an Accountable Care Organization (ACO), servicing over 400,000+ Medicare members with over 1200 providers. Community Medical Group prides itself on providing comprehensive, proactive patient-centered care. MassCare’s programs align well with our mission of enhancing patient care through closing care gaps and by adding a clinical pharmacist to our patients’ care team. This enables us to drive down healthcare costs related to Adverse Drug Reactions and Medication Management, while increasing quality outcomes and reaching our ACO goals."

Dan Miller, Co-founder and CFO of MassCare, says, “We are thrilled to begin working with the staff and Providers at Internal Medicine of Milford. They are a large, innovative and extremely well-organized practice. We’re excited to work with the entire organization to bring our pharmacist-led services to their patient population. Our programs aim to provide proactive care to chronically ill patients, with the goal of improving their health and outcomes while ultimately lowering overall healthcare costs.”

ABOUT MASSCARE 
MassCare is a health-tech and services organization that proactively works with patients to change their lifestyle and behaviors, to improve outcomes and close care gaps, therefore lowering the overall cost of healthcare. At the same time, our programs increase the level of reimbursements physicians and hospital systems earn from Medicare and commercial insurance companies.

To learn more about MassCare, LLC. visit https://www.mass.care

ABOUT INTERNAL MEDICINE OF MILFORD 
Internal Medicine of Milford, P.C. is an internal and family medicine practice for adults aged 18 years old and above. We provide comprehensive health services, including acute and preventative care, chronic disease management, pulmonology, in-office testing, and more. We provide compassionate, high-quality care to help you meet your unique healthcare goals and needs.

Our mission is to provide the highest standard of care to our patients and the communities we serve. To achieve our mission, we are dedicated to continually improving the quality of care and services that we deliver; fostering qualified, responsive staff members, and staying updated of advances in administrative services and patient care.

Our vision is to be recognized as a leader in providing innovative, high-quality care. We will set a new standard for delivering responsive, accessible, and compassionate patient care. We will foster an environment that will attract and support highly-skilled and competent physicians and staff.

To learn more about Internal Medicine of Milford, P.C. visit http://www.immct.com

Pharmacists and Annual Wellness Visits

MARCH 29, 2018

Betty Lu, PharmD, and Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP

Medicare Part B provides for its members an annual wellness visit (AWV), given by a Medicare Part B–approved practitioner such as a physician, physician assistant, nurse practitioner, and clinical nurse specialist or a medical professional, such as a pharmacist, who is working under the direct supervision of a physician.1 Patients are eligible if they are members for at least 12 months and have not yet had a visit in the past 12 months.2 There is no co-payment for an eligible Medicare Part B member, and the visit is not subject to a patient’s deductible.2

Pharmacists are continuing to expand their role as health care providers with more direct patient care opportunities. Pharmacists working under the supervision of a physician can provide an AWV, which is an exam that focuses on the patient’s health, allowing them the opportunity to develop a personalized approach to health care and disease prevention.

During an AWV, pharmacists should do an overview of the patient’s family, immunization, medical, social, and surgical histories and compile an updated list of current providers. Routine measurements such as blood pressure, height, and weight should be taken. In addition, the pharmacist should perform necessary screenings, including detection of any cognitive impairment, depression, fall risks, and functional ability. A patient’s list of current OTC or prescription medications should be reviewed and documented. Pharmacists can provide patients with a better understanding of their medications, and they are in a unique position to address and resolve any medication issues. Upon reviewing a patient’s overall health, a pharmacist can provide individualized health advice and recommendations. Patients should also be provided with a schedule that reviews the Medicare Part B– covered preventive services that they may require in the next 5 to 10 years, such as immunizations and various screenings. A comprehensive list of these covered screenings can be found on the Medicare website.2

An annual physical is different from an AWV, as it consists more of a physical examination that includes the auscultation, inspection, palpation, and percussion of the body. Providers who perform these services are gathering information through their senses to determine whether there is a problem. An annual physical is not a service that falls under an AWV, and it is not covered under the Medicare Part B benefits. The cost for services not covered by Medicare Part B can be billed by a supplemental insurance but is ultimately the patient’s responsibility if it is not covered.2

There may seem to be similarities. However, it is important to distinguish between the 2 exams and especially important for the patient to classify the visit as a Medicare AWV so the practitioner can properly bill for the services.

In a physician’s office or a physician-based clinic, a pharmacist may bill services to a physician, using incident-to billing, as long as 9 requirements that Medicare sets forward are met.3 The billing codes used for these services include the Healthcare Common Procedure Coding System code, G0438 for an initial AWV, with a short descriptor of “annual wellness first,” and G0439 for a subsequent AWV, with a short descriptor of “annual wellness subseq.”4

The 9 requirements are:

  • The patient must be seen by the physician first for an evaluation or a service covered by Medicare.

  • An authorization for the service must be provided by the physician in the medical record.

  • The physician must regularly see the patient at a frequency that is fitting for the management of their course of treatment.

  • The service provided by the pharmacist is within a physician’s or Medicare Part B provider’s office or clinic.

  • The service must be medically appropriate to be given in the provider’s office or clinic.

  • The service provided must be within the pharmacist’s scope of practice.

  • The services and supplies must be furnished in accordance with applicable state law and adhere to other laws that affect the services.

  • A physician or a Medicare Part B–approved practitioner must be on the premises when the incident-to services are performed.

  • The pharmacist must be an employee, contracted or leased, of the physician or Medicare Part B–approved provider.

An AWV with a pharmacist can have a significant impact on patient outcomes. In a 3-month study evaluating 300 patient records, clinical pharmacists completed an average of 5.4 interventions, made 272 referrals, ordered 183 diabetes and lipid screenings, offered 370 vaccinations, and made 24 medication and dosage changes during the AWV.5

In supporting the salary of a pharmacist, a study determined that 1070 AWVs a year, which is about 6 visits a day, would be enough to cover this additional cost for a medical practice. This target was more feasible in a larger practice, which would require a lower percentage of total patients. Pharmacists in this setting have the added benefit of providing a patient with a comprehensive medication review while using only about 40% of their time.6

Results from a 2013 US Department of Health & Human Services report showed that just 11% of eligible patients across the nation took advantage of their covered AWV.6 In medical practices in which few physicians have the time to reach most of their Medicare Part B–eligible patients, a pharmacist will not only help in this task but also add value through this collaborative effort between the 2 health care professions.
 Betty Lu, PharmD, is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for Massachusetts College of Pharmacy and Health Sciences University/ Becton, Dickinson and Company in Boston.

Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University in Boston, a faculty preceptor of the MCPHS University/Becton, Dickinson and Company fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.


References

  1. Centers for Medicare & Medicaid Services. Covered medical and other health services. In: Medicare Benefit Policy Manual. Rev 235, 2017. cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 26, 2018.

  2. Physical exam or wellness visit? What Medicare covers. Medicare Made Clear website. blog.medicaremadeclear.com/physical-exam- wellness-visit- what-medicare- covers-2/. Published April 12, 2016. Accessed January 16, 2018.

  3. American Society of Health-System Pharmacists. Pharmacist billing for ambulatory pharmacy patient care services in a physician-based clinic and other non-hospital- based environments- FAQ. ashp.org/-/media/assets/ambulatory- care-practitioner/docs/sacp-pharmacist-billing- for-ambulatory-pharmacy-patient-care-services.pdf. Published May 2014. Accessed January 26, 2018.

  4. Centers for Medicare & Medicaid Services. Annual wellness visit (AWV), including personalized prevention plan services (PPPS). MLN Matters. cms.gov/Outreach-and- Education/Medicare-Learning- Network- MLN/MLNMattersArticles/Downloads/MM7079.pdf. Published 2011. Accessed January 26, 2018.

  5. Alhossan A, Kennedy A, Leal S. Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center. Am J Health Syst Pharm. 2016:73(4):225-228. doi: 10.2146/ajhp150343.

  6. Park I, Sutherland SE, Ray L, Wilson CB. Financial implications of pharmacist-led Medicare annual wellness visits. J Am Pharm Assoc (2003). 2014:54(4):435-440. doi: 10.1331/JAPhA.2014.13234.

Original Post here

The Most Dangerous Fat Is the Easiest to Lose

It’s every weight loss enthusiast’s dream to zap belly fat but, far from pure vanity, there’s actually a reason why having a lot of fat in the abdominal region can be dangerous. Fat is stored all over our body, but how does an expanding waistline grow your risk for chronic illness?

LOCATION, LOCATION, LOCATION

Your body’s fat impacts your health differently depending on where it’s stored. While most fat found on other parts of our bodies (think arms, legs, buttocks) are considered “subcutaneous fat,” belly fat is more likely to be “visceral.”

PINCHABLE VERSUS PRESSABLE

“Subcutaneous fat” is the pinchable, squishy fat right between your skin and muscle that helps keep you warm, cushions you against shock, and stores extra calories. “Visceral fat” stores calories too, but isn’t as pinchable because it is located in and around your organs. It’s hidden deep within the belly region, which is what makes it firm (rather than squishy) when you press it.

PROXIMITY

Fat doesn’t just store calories—it’s a living tissue capable of producing and releasing hormones that affect your other organs. Because visceral fat sits near our organs, its release of these chemicals is poorly situated. Having more visceral fat can raise your LDL (a.k.a. “bad” cholesterol) and blood pressure. Visceral fat can also make you less sensitive to insulin, which increases your risk for Type 2 Diabetes.

TELLING BAD BELLY FAT APART

Even if you’re thin, you can still have visceral fat around the abdominal region—being “skinny” doesn’t necessarily mean you’re healthy. There’s no sure-fire way to tell visceral from subcutaneous fat short of an expensive CT scan, but it’s important for you to get a rough idea of what your visceral stores are. Here are a few tricks to figure out where your belly stands:

APPLES AND PEARS

You’re probably wondering, “What does fruit have to do with it?” These two fruits give a quick visual of where most of your fat is stored on the body. Pears tend to store fat in the lower extremities (hips, thighs, buttocks) as subcutaneous fat while apples tend to store fat in the upper region (belly, chest) as visceral fat. It takes a quick inspection, but this is an imperfect way to tell these two fats apart.

WAIST CIRCUMFERENCE (WC)

Feel for the top of your hip bone (it’s at the same level as the top of your belly button) and circle a tape measure around this point. Remember to relax and don’t suck in your gut (be honest!). Take 2-3 measurements and figure out the average. Men should have a WC of less than 40 inches (102 cm) and women should have a WC of less than 35 inches (89 cm).

WAIST-TO-HIP RATIO

The waist-to-hip ratio (WHR) takes the circumference of your waist (see above) and divides it by the circumference of your hips. To measure your hips, stand in front of a mirror then figure out the widest part of your butt and measure that circumference. Then use this formula:
WHR = (Waist circumference) / (Hip circumference).
Men should have a WHR of less than 1 while women should have a WHR of less than 0.8.

KNOW YOUR FAMILY HEALTHY HISTORY

If your parents or siblings have insulin resistance, heart disease or non-alcoholic fatty liver, you may be at a greater risk for storing visceral fat. Keeping an eye on your visceral fat may be beneficial, but know that the causes of these chronic diseases are complex. If you’re in doubt, it’s best to speak with your healthcare provider.

BANISHING VISCERAL FAT

If you fall in the normal range for WC and WHR, that’s great! Keep working at your weight goals as you see fit. If you’re not there, don’t despair. Because of its proximity to the liver, visceral fat is usually the easier fat to burn. It’s the less risky subcutaneous fat that likes to stick around.

Unfortunately, you can’t forcefully spot reduce fat around your belly no matter how many crunches you do. The next best thing is to live a healthy lifestyle:

Go beyond weight tracking. You can track your waist, hip and even neck circumference in the app. Use this feature to see how your measurements change over time as you lose weight.

Sweat for 30-60 minutes each day. Visceral fat responds well to regular endurance exercises, such as running, biking, rowing, swimming, that elevate your heart rate. As your body uses fat to fuel exercise, it’ll start using up your visceral stores.

Eat a well-balanced diet. Eat a diet high in whole grains, fresh fruits and vegetables, and lean protein with calories set for gradual weight loss (e.g. about 1-2 pounds per week). Cut way back on added sugars and alcohol since these nutrients will more likely end up as visceral fat.

Sleep more, stress less. It’s easier said than done, but in order to take care of your physical body, you have to take care of your mental state. Sleep loss and stress can sabotage your health and fitness goals. Remember, it’s not just about your health; it’s about your happiness, too.

New Research Reaffirms Physician Shortage

Shortages Likely to Have Significant Impact on Patient Care

The United States continues to face a projected physician shortage over the next decade, creating a real risk to patient care, according to new data released by the Association of American Medical Colleges (AAMC). The latest projections continue to align with previous estimates, showing a projected shortage of between 40,800 and 104,900 doctors.

For the third consecutive year, the Life Science division of the global information company, IHS Markit, conducted a study of physician supply and demand on behalf of the AAMC—modeling a wide range of health care and policy scenarios, such as payment and delivery reform, increased use of advanced practice nurses and physician assistants, and delays in physician retirements. This year’s report extended the date of the projections by five years, from 2025 to 2030, to account for the time needed to train a physician who would start medical school in 2017. The report also includes an expanded section modeling the additional demand for physicians that would be generated by health care utilization equity.

“The nation continues to face a significant physician shortage. As our patient population continues to grow and age, we must begin to train more doctors if we wish to meet the health care needs of all Americans,” said AAMC President and CEO Darrell G. Kirch, MD.

The report aggregates the shortages in four broad categories: primary care, medical specialties, surgical specialties, and other specialties. By 2030, the study estimates a shortfall of between 7,300 and 43,100 primary care physicians. Non-primary care specialties are expected to experience a shortfall of between 33,500 and 61,800 physicians.

These findings are largely consistent with the 2015 and 2016 reports. In particular, the supply of surgical specialists is expected to remain level, while demand increases. The study also finds that the numbers of new primary care physicians and other medical specialists are not keeping pace with the health care demands of a growing and aging population.

“By 2030, the U.S. population of Americans aged 65 and older will grow by 55 percent, which makes the projected shortage especially troubling,” Kirch said. “As patients get older, they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe.”

Expanding on last year’s findings, the new report also includes an analysis of the needs and health care utilization of underserved populations. These data show that if the barriers to utilization were removed for these patients, and all Americans accessed health care at the same levels as insured, non-Hispanic white populations, the United States would have needed up to 96,800 doctors in 2015. Nearly three-quarters of those physicians would be needed in metropolitan areas. This figure is in addition to the projected workforce shortage based on current practice patterns.

“Not only do these utilization equity data highlight the need for the nation to train more doctors, they also demonstrate the importance of a diverse health care workforce. Many of those who underutilize health care—despite their need—are from racial and ethnic minority backgrounds,” Kirch said. “A diverse and culturally competent workforce will enable us to provide the care all Americans need and deserve.”

To help alleviate the physician shortage, the AAMC supports a multipronged solution, including expanding medical school class size, innovating in care delivery and team-based care, making better use of technology, and increasing federal support for an additional 3,000 new residency positions per year over the next five years.

“We urge Congress to approve a modest increase in federal support for new doctors,” Kirch said. “Expanded federal support, along with all medical schools and teaching hospitals working to enhance education and improve care delivery, would be a measured approach to solving what could be a dangerous health care crisis.”


The Association of American Medical Colleges is a not-for-profit association dedicated to transforming health care through innovative medical education, cutting-edge patient care, and groundbreaking medical research. Its members are all 152 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 51 Department of Veterans Affairs medical centers; and more than 80 academic societies. Through these institutions and organizations, the AAMC serves the leaders of America’s medical schools and teaching hospitals and their more than 173,000 full-time faculty members, 89,000 medical students, 129,000 resident physicians, and more than 60,000 graduate students and postdoctoral researchers in the biomedical sciences.

MassCare Announces New Client with Singing River Health System


Extends MassCare’s leadership in Annual Wellness Visit (AWV) and Chronic Care Management (CCM) solutions for Hospital Systems and Healthcare Providers

ST. PETERSBURG, FLA. & JACKSON COUNTY, MISS. (PRWEB) FEBRUARY 01, 2019

MassCare, LLC announced that it has been selected as the Annual Wellness Visit (AWV) and Chronic Care Management (CCM) solutions provider of choice for Singing River Health System, a mission-driven provider of health services and one of the largest employers on the Mississippi Gulf Coast. MassCare’s, AWV and CCM solutions are being deployed by Singing River to proactively address the healthcare needs of its 5,000+ Medicare patient population.

The selection of MassCare as Singing River’s AWV & CCM program provider is the result of an exhaustive study of available program providers by Singing River’s Senior management team.

MassCare has grown to be one of the most respected and admired AWV & CCM program providers in the country. Built upon reputation, MassCare is a leader in bringing both staff and technology solutions to the healthcare industry, offering customers a unique array of services unavailable elsewhere.

"We compared a range of program providers," said Charlie Brinkley, Singing River's Chief Financial Officer. "MassCare stood out for its overall approach and ease of integration into our existing practice processes. By adding MassCare’s clinical pharmacists into our ambulatory settings we’re able to offer patients with chronic conditions unparalleled, proactive care." 
Brinkley continued, “We wanted to stay ahead of the curve related to the transition from Sick Care to Value-Based Care as defined and required by the Centers for Medicare and Medicaid Services (CMS).”

Jake Michel, co-founder and CEO of MassCare, says, “Our success with new customer, Singing River Health System further demonstrates our position as the market leader in providing Value-Based Care programs to hospital systems within ambulatory settings, as well as, individual healthcare providers. Our programs aim to provide proactive care to our customer’s chronically ill patients, with the goal of improving their health and outcomes and ultimately lowering the overall costs of healthcare.”

ABOUT MASSCARE 
MassCare proactively works with chronically ill patients to change their lifestyle and behaviors to improve outcomes and therefore lower the overall cost of healthcare. At the same time, our programs increase the level of reimbursements physicians and hospital systems earn from Medicare and commercial insurance companies. 
To learn more about MassCare, LLC. visit https://www.mass.care/

ABOUT SINGING RIVER HEALTH SYSTEM 
Singing River Health System is the community based, not-for profit healthcare provider for Jackson County and surrounding areas on the Mississippi Gulf Coast. As one of the county’s largest employers, the system offers award winning, comprehensive care for every age and stage. Singing River Health System is committed to the highest quality standards, and is a Blue Cross Blue Shield Blue Distinction Center of Excellence in Knee & Hip Replacement and Cardiac Care. 


We provide critical health services, numerous community outreach programs and charitable services and educational programs. We strengthen the local economy by recruiting over 300 of the very best physicians and other professionals to our community while providing good jobs, wages and benefits to more than 2,400 employees and their families. 


Through this dedication, we help improve the health of the community while making it a better place to live and work. We are honored to be the caregiver of choice. Visit https://www.singingriverhealthsystem.com to learn more.

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The MIPS 2018 Data Submission Period is Now Open

MIPS Eligible Clinicians Can Start Submitting Data for 2018 through April 2

The Centers for Medicare & Medicaid Services (CMS) has officially opened the data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in Year 2 (2018) of the Quality Payment Program. With the exceptions noted in the paragraph below, data can be submitted and updated any time from January 2, 2019 to April 2, 2019.

Please note, CMS Web Interface users need to report their Quality performance category data between January 22 and March 22, 2019. Also, for clinicians who reported Quality measures via Medicare Part B claims throughout the 2018 performance year, we’ll receive your quality data from claims processed by your Medicare Administrative Contractor, and claims for services furnished during 2018 must be processed within 60 days after the end of the 2018 performance period.

MassCare can help you to submit your MIPS data. Contact us to find out how.

For more information on the Quality Payment Program, see: https://qpp.cms.gov/

A Discussion on Creating Value in Healthcare

It’s time to take a pragmatic approach to value in healthcare. That’s what Ethan Berke, MD, MPH, chief medical officer of population health solutions and vice president of clinical innovation at Optum, thinks.

On the frontlines working with providers and large payers across the health system, Dr. Berke has continually challenged preconceived notions of what value looks like. He joined Optum
after serving as the medical director of clinical design and innovation at Dartmouth-Hitchcock Health System. At D-HHS he was also chief medical officer of ImagineCare, a 24/7 nurse-led, coordinated care model that leverages remote medical sensing and machine learning analytics.

Given his unique position of working with organizations to collaborate across the health system, Becker’s Hospital Review recently asked Dr. Berke to share his perspectives on best approaches for creating value in healthcare.

Download and read the full article here.

MassCare to Attend IHI Conference Orlando

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The four-day conference has been the home of quality improvement (QI) in health care, bringing together health care visionaries, improvement professionals, world leaders, industry newcomers, and beyond.

The IHI National Forum is the premier "meeting place" for people committed to the mission of improving the quality and value of health care. The annual event draws more than 5,000 attendees from around the world from a variety of organizations and job titles.

MassCare will be exhibiting at this event. Come visit us at Booth #103.

For more Information, clink here.

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Pharmacists and Annual Wellness Visits

Medicare Part B provides for its members an annual wellness visit (AWV), given by a Medicare Part B–approved practitioner such as a physician, physician assistant, nurse practitioner, and clinical nurse specialist or a medical professional, such as a pharmacist, who is working under the direct supervision of a physician.1 Patients are eligible if they are members for at least 12 months and have not yet had a visit in the past 12 months.2 There is no co-payment for an eligible Medicare Part B member, and the visit is not subject to a patient’s deductible.2

Pharmacists are continuing to expand their role as health care providers with more direct patient care opportunities. Pharmacists working under the supervision of a physician can provide an AWV, which is an exam that focuses on the patient’s health, allowing them the opportunity to develop a personalized approach to health care and disease prevention.

During an AWV, pharmacists should do an overview of the patient’s family, immunization, medical, social, and surgical histories and compile an updated list of current providers. Routine measurements such as blood pressure, height, and weight should be taken. In addition, the pharmacist should perform necessary screenings, including detection of any cognitive impairment, depression, fall risks, and functional ability. A patient’s list of current OTC or prescription medications should be reviewed and documented. Pharmacists can provide patients with a better understanding of their medications, and they are in a unique position to address and resolve any medication issues. Upon reviewing a patient’s overall health, a pharmacist can provide individualized health advice and recommendations. Patients should also be provided with a schedule that reviews the Medicare Part B– covered preventive services that they may require in the next 5 to 10 years, such as immunizations and various screenings. A comprehensive list of these covered screenings can be found on the Medicare website.2

An annual physical is different from an AWV, as it consists more of a physical examination that includes the auscultation, inspection, palpation, and percussion of the body. Providers who perform these services are gathering information through their senses to determine whether there is a problem. An annual physical is not a service that falls under an AWV, and it is not covered under the Medicare Part B benefits. The cost for services not covered by Medicare Part B can be billed by a supplemental insurance but is ultimately the patient’s responsibility if it is not covered.2

There may seem to be similarities. However, it is important to distinguish between the 2 exams and especially important for the patient to classify the visit as a Medicare AWV so the practitioner can properly bill for the services.

In a physician’s office or a physician-based clinic, a pharmacist may bill services to a physician, using incident-to billing, as long as 9 requirements that Medicare sets forward are met.3 The billing codes used for these services include the Healthcare Common Procedure Coding System code, G0438 for an initial AWV, with a short descriptor of “annual wellness first,” and G0439 for a subsequent AWV, with a short descriptor of “annual wellness subseq.”4

The 9 requirements are:

  • The patient must be seen by the physician first for an evaluation or a service covered by Medicare.

  • An authorization for the service must be provided by the physician in the medical record.

  • The physician must regularly see the patient at a frequency that is fitting for the management of their course of treatment.

  • The service provided by the pharmacist is within a physician’s or Medicare Part B provider’s office or clinic.

  • The service must be medically appropriate to be given in the provider’s office or clinic.

  • The service provided must be within the pharmacist’s scope of practice.

  • The services and supplies must be furnished in accordance with applicable state law and adhere to other laws that affect the services.

  • A physician or a Medicare Part B–approved practitioner must be on the premises when the incident-to services are performed.

  • The pharmacist must be an employee, contracted or leased, of the physician or Medicare Part B–approved provider.

An AWV with a pharmacist can have a significant impact on patient outcomes. In a 3-month study evaluating 300 patient records, clinical pharmacists completed an average of 5.4 interventions, made 272 referrals, ordered 183 diabetes and lipid screenings, offered 370 vaccinations, and made 24 medication and dosage changes during the AWV.5

In supporting the salary of a pharmacist, a study determined that 1070 AWVs a year, which is about 6 visits a day, would be enough to cover this additional cost for a medical practice. This target was more feasible in a larger practice, which would require a lower percentage of total patients. Pharmacists in this setting have the added benefit of providing a patient with a comprehensive medication review while using only about 40% of their time.6

Results from a 2013 US Department of Health & Human Services report showed that just 11% of eligible patients across the nation took advantage of their covered AWV.6 In medical practices in which few physicians have the time to reach most of their Medicare Part B–eligible patients, a pharmacist will not only help in this task but also add value through this collaborative effort between the 2 health care professions.



References

  1. Centers for Medicare & Medicaid Services. Covered medical and other health services. In: Medicare Benefit Policy Manual. Rev 235, 2017. cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed January 26, 2018.

  2. Physical exam or wellness visit? What Medicare covers. Medicare Made Clear website. blog.medicaremadeclear.com/physical-exam- wellness-visit- what-medicare- covers-2/. Published April 12, 2016. Accessed January 16, 2018.

  3. American Society of Health-System Pharmacists. Pharmacist billing for ambulatory pharmacy patient care services in a physician-based clinic and other non-hospital- based environments- FAQ. ashp.org/-/media/assets/ambulatory- care-practitioner/docs/sacp-pharmacist-billing- for-ambulatory-pharmacy-patient-care-services.pdf. Published May 2014. Accessed January 26, 2018.

  4. Centers for Medicare & Medicaid Services. Annual wellness visit (AWV), including personalized prevention plan services (PPPS). MLN Matters. cms.gov/Outreach-and- Education/Medicare-Learning- Network- MLN/MLNMattersArticles/Downloads/MM7079.pdf. Published 2011. Accessed January 26, 2018.

  5. Alhossan A, Kennedy A, Leal S. Outcomes of annual wellness visits provided by pharmacists in an accountable care organization associated with a federally qualified health center. Am J Health Syst Pharm. 2016:73(4):225-228. doi: 10.2146/ajhp150343.

  6. Park I, Sutherland SE, Ray L, Wilson CB. Financial implications of pharmacist-led Medicare annual wellness visits. J Am Pharm Assoc (2003). 2014:54(4):435-440. doi: 10.1331/JAPhA.2014.13234.

  7. Betty Lu, PharmD, is a graduate of Temple University School of Pharmacy and a fellow of global medical affairs for Massachusetts College of Pharmacy and Health Sciences University/ Becton, Dickinson and Company in Boston.

  8. Jennifer D. Goldman, RPh, PharmD, CDE, BC-ADM, FCCP, is a professor of pharmacy practice at Massachusetts College of Pharmacy and Health Sciences (MCPHS) University in Boston, a faculty preceptor of the MCPHS University/Becton, Dickinson and Company fellowship in medical affairs, and a clinical pharmacist at Well Life in Peabody, Massachusetts.