Annual Wellness Visit Fraud: A Physician’s Name Cannot Do the Work

Annual wellness visit fraud involves false Medicare claims about the preventive work performed or the physician oversight behind it. A claim can carry a wellness code and a physician’s name while the people inside the practice know a different story about who saw the patient and what happened. If you schedule the visits, perform the assessments or code the claims, you may know exactly where the billed service parts company with the work.

The useful questions in this kind of physician billing fraud are concrete. What prevention work did the patient receive? What does the medical record show? Who performed the service, and who supplied the oversight the claim depended on? Penn State Health and Tri-Area Community Health show why those questions belong together, but need separate answers.

What Does Medicare Pay for in an Annual Wellness Visit?

Medicare pays for a personalized prevention plan with specified assessment, risk and screening work. An annual wellness visit is a different service from a routine comprehensive physical. Its billing code represents the preventive work, rather than simply an appointment labeled wellness on the calendar.

The Centers for Medicare & Medicaid Services requirements connect the health risk assessment to medical and family history, medications, the health care team and measurements. The first visit also includes cognitive assessment, review of depression risk, daily functioning and safety, and screening for potential substance use disorders. Current opioid prescriptions require a review of risks, pain and treatment.

The work leads to a written screening schedule, a list of risk factors and conditions, and personalized advice and referrals. For the employee reviewing a wellness claim, those are concrete parts of the service to compare with the chart and what the patient received.

The subsequent visit updates the risk assessment, histories, provider list, screening schedule and risk factors. It includes measurements and cognitive assessment, with personalized advice and referrals updated as necessary. For an insider, the distinction matters: a later visit has its own work to support, even when the practice already has a prevention plan in the chart.

How Often Can Medicare Pay for an Annual Wellness Visit?

Medicare permits G0438 for the first annual wellness visit and G0439 for subsequent visits, with an annual wellness visit billable only once in a 12-month period. Neither code is billable within 12 months of the initial preventive physical examination, the separate benefit billed under G0402. The first-visit code does not reset with a new calendar year. The prior service date belongs beside the new claim when we examine repeated wellness billing.

The service depends on its required elements rather than a universal minimum number of minutes. A long appointment does not supply a missing assessment, and a recurring calendar entry does not establish that the prevention work occurred. We connect the date and code to the service the patient actually received.

Who Can Perform the Visit Behind the Physician’s Name?

The Centers for Medicare & Medicaid Services permit an annual wellness visit performed by a physician, a physician assistant, a nurse practitioner or a certified clinical nurse specialist. The agency also permits a medical professional or team of medical professionals directly supervised by a physician. Its examples of medical professionals include health educators, registered dietitians, nutrition professionals and other licensed practitioners.

Medicare also pays for G0438 and G0439 via telehealth. For a remote visit, we examine who did the assessment and planning, what role that person held and what physician involvement supported the claim. The name on the bill is the beginning of that inquiry.

The broader incident-to billing problem also requires looking past a physician’s signature to the actual worker and applicable supervision. Employment, ownership and a later co-signature alone do not establish the conditions for that billing. For wellness visits, the service’s own performer rules and the clinic’s payment setting belong in the comparison.

Penn State Health’s Wellness Visit Settlement

Penn State Health agreed to pay $11,712,336 to resolve civil allegations that its Medicare annual wellness visit claims were unsupported by the medical record. The Justice Department’s February 2024 announcement described a multi-hospital healthcare system that had voluntarily disclosed the billing problem. The disclosed claims covered December 2015 through November 2022.

According to the announcement, Penn State discovered the problems, took prompt corrective action and disclosed the claims to the United States Attorney’s Office. For someone who reviews wellness claims, the comparison between the billed service and the medical record reaches the same question: what supports the payment Medicare made?

Tri-Area’s Settlement Over Visits Billed Under Uninvolved Physicians

Tri-Area Community Health agreed to a $513,730 civil settlement over allegations that pharmacists provided annual wellness visits without appropriate physician oversight and the visits were billed under uninvolved physicians’ names. The settlement agreement identifies the claims as involving G0438 and G0439 and expressly invokes the False Claims Act. The government’s allegations cover August 2022 through December 2025. The total includes a credit for $321,076 already repaid to Medicare.

The government alleged that the pharmacist visits lacked physician oversight, physical or virtual physician presence, or otherwise appropriate physician supervision. It also alleged that the physicians whose names appeared on the bills were not involved in the visits. We see a physician’s name standing in for physician involvement in the government’s account. A name, not oversight.

Tri-Area is a federally qualified health center, which has a distinct clinic payment framework. The Centers for Medicare & Medicaid Services identify G0468 for a health-center visit that includes an annual wellness visit or initial preventive physical examination and the usual bundle of covered services. The payment setting therefore belongs beside the professional service when we assess a similar concern in another clinic.

The Penn State settlement puts the medical record’s support for the billed service at the center. Tri-Area puts the actual performer and physician involvement there. Together, they show why a review needs both the clinical work and the billing identity, even when a visit appears in the schedule.

What Evidence Does a Whistleblower Need?

Useful evidence connects the Medicare claim to the visit, the clinical record, the actual performer and the required oversight. The service date, code, assessment, prevention plan and practitioner identity describe different parts of the same transaction. We work with the insider who can explain how those parts fit together and where they contradict each other.

Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse, published in the Journal of AHIMA in 2017, describes comparing the treatment date, treatment and signature with the patient record. For the staff member who knows what happened behind a chart entry, its next point matters: you may be the witness the documentation cannot replace.

The clinical record describes the service. The person doing the work can explain what an entry means, who entered the information, who completed the assessment and who decided the visit was ready to bill. For a wellness visit, that account may connect an apparently complete record to an assessment or supervisory step that was missing in practice.

What About a Separate Office Visit on the Same Day?

Medicare may also pay for a significant, separately identifiable, medically necessary evaluation and management service provided with the wellness visit. The Centers for Medicare & Medicaid Services identify CPT codes 99202 through 99205 and 99211 through 99215 with modifier 25 for that additional service. The additional payment depends on the separate work treating the patient’s illness or injury.

For a coder or clinician, the question is what work supports each charge. Modifier 25 billing needs its own clinical basis alongside the wellness assessment and prevention plan. We examine the additional service with the wellness claim so that each payment connects to the work it represents.

When the Billing Supports a Whistleblower Case

A physician-practice qui tam case connects false claims to the people and decisions that caused them. In wellness billing, that may mean the person who understood the missing work, knew which physician was uninvolved or decided the claims should go forward. We bring the claim, the clinical facts and that inside knowledge together.

A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers. We shape your wellness billing case with you from the first call and bring in whistleblower lawyers who understand Medicare preventive-service cases. Your knowledge of how the practice actually operates gives that conversation its substance.

When You Know What Happened in the Visit

If the wellness claims leaving your practice describe work or physician involvement you know was missing, speak to one of our Whistleblower Experts about the visits behind those claims. We work beside you to build the case from the clinical record, the billing decisions and the people who know what happened. We bring in Medicare fraud whistleblower lawyers who know wellness visit billing and stay with you to build your strongest case.