What is a wellness exam?
An annual wellness exam is a comprehensive preventative exam with your primary care provider for the sole purpose of preventative care.
An annual exam does not include discussion of new problems or detailed review of chronic conditions.
Annual exams may also be called routine check-ups, yearly exams, an annual pap, or preventive visit.
Will my insurance pay for a wellness exam?
Most health plans will pay for one wellness or preventative exam per year. Your insurance provider may consider this to be once per calendar year or one year and one day since the date of your last wellness exam. If you have had any other visit billed as preventative during this time period your plan is likely to deny your wellness exam. This would include a well-woman exam or annual pap smear. Your plan may not pay for all testing and/or labs ordered during your wellness exam. If your provider has a concern and orders diagnostic testing and/or labs during your exam you may be held financially responsible. It is the patient’s responsibility to check with their insurance provider to see what is covered under their wellness benefit and to ensure they are eligible prior to scheduling their annual wellness exam.
What is the difference between a wellness exam and a problem visit?
Preventative visits and tests ordered by your provider can help you stay healthy and catch problems early. Screening tests and evaluations are done during a wellness visit. These tests include mammogram, colonoscopy, bone density, etc.
Diagnostic visits and testing are used to diagnose a current health problem. Diagnostic tests are ordered by your provider when you have symptoms and they want to find out why. For example, your provider might want you to have a test because of your age or family history, that’s preventive care, but if it’s because you’re having symptoms of a problem, that’s diagnostic care.
Can I have a wellness exam and problem visit at the same time?
Yes, but you and your insurance will be billed a separate charge for the problem visit. You may have a copay for the problem visit.
Should your wellness exam turn into a diagnostic or problem-oriented visit we will bill accordingly.
We cannot rebill problem visits as a wellness visit, so please be careful to let us know what your expectations are the day of the visit!
Medicare- Annual preventive exam
The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical. Also, this service is similar to but separate from the one-time Welcome to Medicare preventive visit.
Medicare Part B covers the Annual Wellness Visit if:
You have had Part B for over 12 months
And, you have not received an AWV in the past 12 months
Additionally, you cannot receive your AWV within the same year as your Welcome to Medicare preventive visit.
During your first Annual Wellness Visit, your PCP will develop your personalized prevention plan. Your PCP may also:
Check your height, weight, blood pressure, and other routine measurements
Give you a health risk assessment
This may include a questionnaire that you complete before or during the visit. The questionnaire asks about your health status, injury risks, behavioral risks, and urgent health needs.
Review your functional ability and level of safety
This includes screening for hearing impairments and your risk of falling.
Your doctor must also assess your ability to perform activities of daily living (such as bathing and dressing), and your level of safety at home.
Learn about your medical and family history
Make a list of your current providers, durable medical equipment (DME) suppliers, and medications
Medications include prescription medications, as well as vitamins and supplements you may take
Create a written 5-10 year screening schedule or check-list
Your PCP should keep in mind your health status, screening history, and eligibility for age-appropriate, Medicare-covered preventive services
Screen for cognitive impairment, including diseases such as Alzheimer’s and other forms of dementia
Medicare does not require that doctors use a test to screen you. Instead, doctors are asked to rely on their observations and/or on reports by you and others.
Screen for depression
Provide health advice and referrals to health education and/or preventive counseling services aimed at reducing identified risk factors and promoting wellness
Health education and preventive counseling may relate to weight loss, physical activity, smoking cessation, fall prevention, nutrition, and more.
AWVs after your first visit may be different. At subsequent AWVs, your doctor should:
Check your weight and blood pressure
Update the health risk assessment you completed
Update your medical and family history
Update your list of current medical providers and suppliers
Update your written screening schedule
Screen for cognitive issues
Provide health advice and referrals to health education and/or preventive counseling services
If you qualify, Original Medicare covers the Annual Wellness Visit at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover AWVs without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.
During the course of your AWV, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.