THE “WELCOME TO MEDICARE” VISIT
(ALSO KNOWN AS THE INITIAL PREVENTIVE PHYSICAL EXAMINATION, OR IPPE)
If you are a primary care physician, you may just now be hearing about the “Welcome to Medicare” visit, also called the IPPE. Depending on how carefully you code Medicare visits and how closely you communicate with the billing side of your practice, you may or may not already know what Medicare has historically paid for and what they will not reimburse. You may already know that they do not pay for the commonly-accepted and frequently-requested yearly physical examination. The IPPE is not a way to stop Medicare payments for physical examinations, because they did not pay for them before. In fact, the IPPE is an added benefit for seniors, and a chance for you to practice preventive medicine at no cost to Medicare beneficiaries.
There are many reasons why the IPPE seems to be provoking strong reactions from physicians. Partly this is because it gives people new to Medicare a visit that is nothing like the yearly “head-to-toe” physical. Doctors are afraid of a negative response from their patients who are expecting a traditional physical examination. The IPPE also contains a long list of requirements that have not been part of many doctors’ established ways of delivering care. Its focus on prevention is a dramatic shift from a diagnosis-centered doctor visit.
Many physicians feel overburdened by the enormous changes in medical care that all seem to be arriving at once, and believe, incorrectly, that all of them stem from the Affordable Care Act (ACA). In fact, the IPPE was not invented as part of the ACA. The IPPE was first defined by the Medicare Modernization Act, signed into law by President George W. Bush in 2003 and implemented in 2005. Since then, the requirements of the IPPE have been updated and benefits have been expanded. Because of the ACA, there is no copay or deductible for the IPPE, which is a one-time exam. Patients pay nothing for the IPPE if it is done during the first 12 months a person has Medicare, whereas in the past it had to be done in the first 6 months in order to be covered.
Also, there is now an annual wellness exam available, a similar benefit that patients get for free on a yearly basis. This was added as part of the Affordable Care Act. So, between the two types of visits, seniors get a yearly appointment focusing on preventive healthcare and wellness which costs them nothing. This includes certain laboratory tests as well as a one-time EKG, free, as long as the doctor follows Medicare guidelines.
But how do doctors get paid? Medicare never did pay for a yearly physical examination. Some doctors received payments for physicals by using creative coding and billing for a specific illness and treatment rather than a physical exam. At other times, patients got the bills, not just from their doctors, but also from the laboratory or x-ray facility that did the related testing. Needless to say, these people were upset. Many physicians have no idea whether or not Medicare has been paying them for the care they give or billing their patients. If you do not know, you should speak to billing personnel or others in your practice who handle Medicare billing and know whether or not you are getting paid for what you do. Doctors who work in a group setting, especially in a large group, may have no understanding of this.
So why is this an issue now? The Affordable Care Act mandated the adoption of Electronic Medical Records (EMR), another requirement that many doctors did not willingly or enthusiastically embrace. There are, in fact, many benefits to EMR. The downside, as far as many doctors are concerned, is that these records allow Medicare, as well as insurance companies and anyone else who has the right to look a much easier way to see what doctors are really doing. No one can just scribble in a chart that an examination was done. Everything has to be documented. And for the IPPE, all of the requirements must be visible in the records.
Doctors need to know that EMR systems actually make the IPPE and many other aspects of delivering care to all their patients, not just those with Medicare, easier and more efficient once they learn how to use them. Much of the information needed in an IPPE should be in patients’ records. If not, once the information is gathered for the IPPE, it should be in the EMR and available when needed.
The idea of having to learn how to successfully complete an IPPE in a reasonable amount of time and without upsetting patients is truly a challenge. But it is not impossible. Physicians can learn to do the IPPE without wreaking havoc on their schedules. If they prepare patients for this visit and explain it clearly, they will find that rather than being upset, patients can appreciate something that is going to benefit them in the long run as they face problems that go along with aging.
Back in 2005, a family physician explaining the IPPE said, “Over time, you will become more adept at completing the initial preventive physical exam in a reasonable period. CMS considers the physician/non-physician provider time component of the initial preventive physical exam to be equivalent to a 30-minute 99203 (new patient, level-three E/M code).” This was before EMR.
One problem related to implementing the preventive measures required by Medicare is that they keep changing. Frequently Medicare only issues general guidelines without specifics. Many medical societies try and get information for their members to help them figure out what to do. An example is screening for depression. There are many formal screening tools, but there is also the simplest of all, which are the questions, “Are you feeling sad, blue, or down?” and “Are you able to enjoy your usual activities or are you no longer able to enjoy them?” Anyone who says they are feeling down and cannot enjoy their usual activities should be evaluated for depression.
Here are some practical suggestions:
- Make sure your front office staff understands the IPPE (and the annual wellness visit). They must tell Medicare patients who call for a “physical examination” that Medicare does not cover the expected exam but does give them the benefit of the IPPE for free.
- Front office staff must let the patients know what kind of visit they will be having. There is a sample
letter in an article below (http://www.aafp.org/fpm/2011/0700/p10.html) that can be mailed before the IPPE. There is also a questionnaire that can be used for later annual wellness visits.
- Doctors need to learn what they must do, and what they cannot do, in order to be paid for an IPPE. This may seem overwhelming at first, but comfort with this is an achievable goal. In fact, they may see increased payment for a correctly-done IPPE.
- Doctors should use tools, forms, and ideas from a variety of sources to pick what works best for each of them. A lot of professional organizations have developed ways to meet criteria efficiently and quickly.
- Doctors should explain to patients that the focus on prevention is a way to ensure their health during these years. This is the chance to find a way to prevent a fall and a hip fracture; or an automobile accident due to impaired driving; or arriving at a hospital with a serious, possibly fatal condition without ever having considered what measures a person does or does not want in that case.
While many 65-year-olds are still healthy, they do know that as they get older they will face certain inevitable situations. Many are actually happy to have these issues brought up in advance.
Physicians do not have to offer an IPPE, although their Medicare patients have a right to ask for and receive one. Physicians do not have to take Medicare patients, but there are going to be an increasing number of “Baby Boomers” reaching Medicare age and they are going to need medical care. Not taking Medicare or not doing the IPPE does not mean that you, as a physician, will not have to adopt some of these new measures. Many large medical groups and insurance companies are asking for similar preventive care to be delivered. Some doctors already have their compensation yoked to how well they implement specific guidelines for screening and prevention of illness and not just treatment.
Learning how to do an IPPE is not just good business. It is good medical practice. Your older patients will surprise you if you try and do the IPPE with an open mind.
(See subsequent articles on one doctor’s experience implementing the IPPE, including patient reactions, tips and tricks, and also information on the annual wellness examination.)
To help you get started here are some links:
QUICK REFERENCE INFORMATION:
The ABCs of Providing the Initial Preventive Physical Examination (IPPE). Medicare Learning Network.
(This is a chart you can print with all the requirements for the IPPE, the ABC’s, coding information, and links.)
Medicare Wellness Checkup. Mail this printable form to your patients beforehand or assign time and a staff member to help them fill it out before they see you. This is specifically for the Annual Wellness Visit, to be covered in another article. http://www.aafp.org/fpm/2012/0300/fpm20120300p11-rt1.pdf
Emma Hitt, PhD. A Primer on the “Welcome to Medicare” Visit and the Annual Wellness Visit. Medscape Multispecialty. From Medscape Education Family Medicine. http://www.medscape.org/viewarticle/748527
Randall O. Card, MD, FAAFP. How to Conduct a “Welcome to Medicare” Visit. Fam Pract Manag. 2005 Apr;12(4):27-31. http://www.aafp.org/fpm/2005/0400/p27.html
New Medicare Preventive Services
(with links to other Medicare information)
Probably more information than you want at:
There is an online version of the paper checkup list, a longer online version, copies of articles about the IPPE and wellness exams, plus a lot more information from many different sources if you click on “Information for Health Professionals”
Your Medicare Coverage. Preventive visit & yearly wellness exams.
Your Guide to Medicare’s Preventive Services