Wiki MEDICARE AWE

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LMOuellette

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Hello, I need some assistance. Can someone advise me regarding how often an AWE/Preventative can be done. My intepretation is annually 365 + a day, however my boss is saying we can do in 11th month. We are getting denials for benefit max, and I think if we use the 365+ a day, we will not get so many denials. Also if anyone has a directive I can follow that would be awesome as well. Thanks in advance.
 
KaurS85 said:
The best option would be to call insurance to verify.
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I agree. You have to verify with insurance for that patient's specific benefit plan. It can vary from group to group, even from the same insurer.

My current employer's insurance plan allows one per calendar year. There's no requirement to wait a full 12 months. Technically I could do in December and one in January if that's how I wanted to use my benefit. (I wouldn't, of course, but I could.)
 
In my experience, Medicare is very strict with any benefit that is limited to once per a given time period. If you bill it one day before the time has elapsed, then it will be denied. So if a patient had their AWE today, July 14, 2022, then I would not schedule the next one any sooner than July 15, 2023.
 
See and that is what I am trying to explain to her but she says it is 11 months. I have pulled the preventative worksheet on CMS website that clearly states annual but is there another reference that says 365 + a day or something like that?
 
LMOuellette said:
See and that is what I am trying to explain to her but she says it is 11 months. I have pulled the preventative worksheet on CMS website that clearly states annual but is there another reference that says 365 + a day or something like that?
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Yes, on the CMS Preventive Services Chart (link below) under AWV, it states that the AWV is covered for patients with Part B who "Haven't had an Initial Preventive Physical Exam (IPPE) or AWV within the past 12 months". 11 months isn't going to work.


But if she insists even after seeing that, then just bill them and then you can show her the denials when they come in. Managers have to be responsible for their own decisions.
 
Also, your logic of 365 + 1 would certainly cut down on denials, because then you'd know it would covered--no guesswork involved. As has been noted above, straight Medicare has one rule, but MA plans can be all over the place: 12 months, 12 months + 1 day, calendar year, when the moon is in the 7th house. ;)
 
For additional proof if available like Medicare Noridian contractor, effective dates for each G0432, G0438, & G0439 are available on the portal.
 
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