Can you bill an AWV if Medicare is the secondary payer?
Asked by: Erling Schmidt MD | Last update: August 19, 2025Score: 4.3/5 (64 votes)
Can you bill a patient with Medicare Secondary?
When Medicare is secondary, the primary insurer should always be billed first. The Social Security Act, “prohibits Medicare from making payment if the payment has been made or can reasonably be expected to be made by a third party payer….
What is the Medicare secondary payer rule?
In certain situations, however, federal Medicare Secondary Payer (MSP) law prohibits Medicare from making payments for an item or service when payment has been made, or can reasonably be expected to be made, by another insurer such as a liability plan.
Who can bill for Medicare annual wellness visit?
Medicare Part B covers the Annual Wellness Visit (AWV) if it is furnished by a: • Physician (doctor of medicine or osteopathic medicine) • Physician assistant • Nurse practitioner • Clinical nurse specialist • Medical professional (including a health educator, a registered dietitian, nutrition professional, or other ...
Can Medicare be secondary to a commercial plan?
The group health plan pays first, and Medicare pays second.
What if my plan has opted out? If the group health plan didn't pay your entire bill, your provider should send the bill to Medicare for secondary payment. You may have to pay any costs Medicare or the group health plan doesn't cover.
Medicare Secondary Payer: Don’t Deny Services and Bill Correctly
Can Medicare be a secondary payer rather than a primary payer?
In 1980, Congress passed legislation that made Medicare the secondary payer to certain primary plans in an effort to shift costs from Medicare to the appropriate private sources of payment.
What is a secondary insurance to Medicare is called?
Medicare Supplement Insurance (Medigap) is extra insurance you can buy from a private health insurance company to help pay your share of out-of-pocket costs in. Original Medicare. Original Medicare.
Who is eligible for AWV Medicare?
Who's eligible for the AWV? We cover an AWV for all patients who've had Medicare coverage for longer than 12 months after their first Part B eligibility date and who didn't have an IPPE or AWV within those past 12 months.
Can you bill 99214 and G0439 together?
Medicare does discourage this and says there is too much 'crossover' between these two preventive services. We usually see a 99213 or 99214 with a G0438 or G0439 to represent the problem management outside the AWV. If you bill G0438/G0439 and a 99397, recognize that Medicare does not cover the 99397.
Does Medicare pay for wellness visit?
With Medicare Part B, you can get a wellness visit once a year at no cost to you. Check to make sure the doctor or nurse accepts Medicare when you schedule your appointment.
What are some scenarios where Medicare can be a secondary payer?
This scenario often applies to individuals who are eligible for Medicare due to age but continue to work and have ESI coverage. COBRA Continuation Coverage: When individuals leave their job but choose to continue their group health insurance coverage through COBRA, Medicare can serve as the secondary payer.
What is the 2 2 2 rule in Medicare?
Introduced in the Fiscal Year 2014 Inpatient Prospective Payment System (IPPS) Final Rule, the two-midnight rule specifies that Medicare will pay for inpatient hospital admissions when a physician reasonably expects the patient's care to require a stay that crosses two midnights, and the medical record supports this ...
What is the penalty for Medicare secondary payer?
Penalties against an RRE are up to $1,000 (as adjusted) per instance of noncompliance for each calendar day that a record is late, with a maximum annual penalty of $365,000 per instance. Penalties may be waived if RREs can show “good faith efforts” to report any records identified by CMS as being noncompliant.
Can a doctor refuse to bill secondary insurance?
A: The answers to your questions depend on state law. Some states require physicians to bill all insurers a patient has, without charge, whereas others do not. If the physician has a contract with the secondary insurer, then, by contract, he or she most likely is obligated to submit the bill.
What is the Medicare Secondary Payer Act Part C?
When Medicare Part C entities make conditional payments for accident-related expenses incurred by Medicare beneficiaries, the Medicare Secondary Payer Act entitles them to seek reimbursement of these payments from insurers, known as primary payers, who are responsible for those bills.
Will Medicare pay the primary deductible if they are secondary?
Usually, secondary insurance pays some or all of the costs left after the primary insurer has paid (e.g., deductibles, copayments, coinsurances). For example, if Original Medicare is your primary insurance, your secondary insurance may pay for some or all of the 20% coinsurance for Part B-covered services.
Can you bill Medicare Wellness and Office Visit?
The CMS website states “When you provide an annual wellness visit and a significant, separately identifiable, medically necessary Evaluation and Management (E/M) service, Medicare may pay the additional service. Report the additional CPT code with Modifier-25.
Does an AWV have to be 12 months apart?
Visits must be at least 11 months apart
“In order for Medicare to pay for annual wellness visits, at least 11 full months must have elapsed,” Dr.
Why is Medicare denying G0438?
An Annual Wellness Visit code of G0438 should not be used — and will be denied — because the patient is eligible for the Welcome to Medicare visit during the first year of enrollment. For more information on the Welcome to Medicare visit go-to CMS.
Will Medicare pay for an AWV and E&M same day?
It is essential to explain this to patients prior to their visit either with a phone call, handout, or FAQ letter. The AWV can be performed on the same day as a routine E&M visit (to address problem-based concerns), or it can be separated into its own visit.
Why doesn't Medicare pay for annual physicals?
Annual physicals aren't covered by traditional Medicare because they are excluded by the federal law that governs Medicare. All Medicare plans cover a Welcome to Medicare exam during your first 12 months with Medicare and in subsequent years, an annual wellness exam.
Is an annual physical the same as an AWV?
While a physical includes a full examination and a wellness evaluation, an Annual Wellness Visits focuses solely on a patient's answers to a health risk assessment. It does not typically include any lab work or tests requiring physical contact.
What happens when Medicare is secondary?
Medicare Secondary Payer (MSP) provisions protect Medicare from paying when another entity should pay first. Any entity providing items and services to Medicare patients must determine if Medicare is the primary payer.
Will secondary pay if primary denies?
If a claim is denied by the primary insurance, it is possible to submit the claim to the secondary insurance for consideration. However, the secondary insurance will only cover expenses that are within its coverage limits and not already covered by the primary insurance.
What is dual coverage in Medicare?
People who are entitled to both Medicare and Medicaid, also known as dually eligible individuals, fall into several eligibility groups. These individuals may either be enrolled first in Medicare and then qualify for Medicaid or vice versa.