Medicare coverage

[big john]

Has anybody had this problem. My wife had her annual check up,first time under Medicare. It was declined do to it being preventative care. They only pay for wellness check up. Seem the same to me. Thanks in advance

 

[MissMolly]

Yes. You no longer get ordinary annual physicals under Medicare. You need to read the Medicare & You Handbook. The new one just came out. We received ours yesterday.

https://www.medicare.gov/publications/10050-Medicare-and-You.pdf

 

[MichaelB]

Has anybody had this problem. My wife had her annual check up,first time under Medicare. It was declined do to it being preventative care. They only pay for wellness check up. Seem the same to me. Thanks in advance

This is frequently mentioned in thread discussions on Medicare and is a surprise to many, Medicare does not cover annual preventative physical exams. While others chime 8n here are a couple of threads where it is mentioned

https://www.early-retirement.org/forums/f38/medicare-once-every-12-mos-meaning-105128.html

https://www.early-retirement.org/forums/f38/medicare-wellness-scam-113334.html

 

[Donno]

Call her doctor's office and talk to them, they probably coded the bill wrong.

 

[harllee]

Has anybody had this problem. My wife had her annual check up,first time under Medicare. It was declined do to it being preventative care. They only pay for wellness check up. Seem the same to me. Thanks in advance

I was going to a regular GP and had this problem every year. I would ask for a Medicare Annual Wellness exam, which Medicare will pay, instead the GP's office would code it as an annual physical, which Medicare will not pay I would be stuck with a $350 bill. I got tired of this and switched to a geriatric doctor, his office knows how to code my visits correctly and Medicare pays the whole thing.

 

[RetMD21]

I was going to a regular GP and had this problem every year. I would ask for a Medicare Annual Wellness exam, which Medicare will pay, instead the GP's office would code it as an annual physical, which Medicare will not pay I would be stuck with a $350 bill. I got tired of this and switched to a geriatric doctor, his office knows how to code my visits correctly and Medicare pays the whole thing.

Sounds like the best option

 

[lawman]

. I got tired of this and switched to a geriatric doctor, his office knows how to code my visits correctly and Medicare pays the whole thing.

One would expect geriatric providers to do better but don't assume geriatric care is any different.. I switched from one to a P.A. because whoever was coding for them had no clue..Have not had a problem since switching..

 

[MBSC]

Yes. You no longer get ordinary annual physicals under Medicare.

This statement is accurate for original Medicare. Most Medicare Advantage plans cover the more comprehensive annual physical. They're willing to spend a little on preventive care to avoid more expensive profit-reducing care later.

For those patients with a Medicare Advantage plan, an annual physical may be an included benefit.

https://blog.prevounce.com/why-medicare-does-not-cover-annual-physical-exam

 

[djsander]

Medicare gets confusing pretty quick. The correct terminology is within the first year is A welcome to medicare exam. However, buried in the cms.gov site they have a section on the different types of exams. The first one they call initial preventative physical exam (Welcome to Medicare). After 12 months on Medicare and every year you can have an annual wellness visit. The other one is Routine physical exam which they don’t pay. The important thing is not what they are called, but the codes they use. However, communicating to the provider is important. My wife had her first exam this week and the doctor seemed to know how to code as she wanted certain test done and said she had to code them right. The billing department told her the same thing as she was getting clarification on billing. They said it will be all be coded to get paid and if there is a problem call them. It really comes down to a doctors practice that knows the proper codes.

 

[CardsFan]

Also note that if you are on any maintenance drugs that require monitoring (I am for HBP and cholesterol), Medicare will cover these visits and associated bloodwork. So I typically see my PCP twice a year and have been fully covered (except for Plan G deductible, of course).

Also, due to past instances of skin cancer, I am on a quarterly schedule for exams with my Dermatologist. Never had a problem with Medicare coverage for these either.

I don't understand why the OP's doc did not code as a Welcome to Medicare exam. From what I saw on EOB's for this and the annual Wellness exam, they get a lot more money for these than they do for a normal visit. Of course, they may get even more if it is not covered and you have to pay out of pocket

Bottom line: never ask for a physical, go for a specific purpose and it will be covered.

 

[harllee]

Sometimes it is a "coding" problem, sometimes the doctor and his or her billing department just want more money out of the patient. Medicare pays the doctor around $150 for a "Medicare annual wellness exam". On the other hand my former GP billed me $380 for an "annual physical" even though I had clearly requested a Medicare annual wellness exam. I finally got the billing department to code it correctly but I fired that doctor shortly thereafter.

 

[Pluperfect]

I don't understand why the OP's doc did not code as a Welcome to Medicare exam.

But depending on what the doctor did, it might not qualify as a Welcome to Medicare exam.

Here is what is included in a Welcome to Medicare exam (which they actually call a "visit" in their description, which sounds more accurate to me because there's no actual physical exam):

This visit includes a review of your medical and social history related to your health. It also includes education and counseling about preventive services, including these:

• Certain screenings, flu and pneumococcal shots, and referrals for other care, if needed.
• Height, weight, and blood pressure measurements.
• A calculation of your body mass index.
• A simple vision test.
• A review of your potential risk for depression and your level of safety.
• An offer to talk with you about creating advance directives.
• A written plan letting you know which screenings, shots, and other preventive services you need.

Did the OP's wife receive all of these elements? If not, then it wasn't a Welcome to Medicare visit, and the problem isn't the coding; the problem is that the service provided doesn't meet the criteria for a Welcome to Medicare visit.

What's less clear (to me) is whether it's still a Welcome to Medicare visit if all of the criteria are met, but other services are provided, too (e.g., actually laying hands on the patient, which a Welcome to Medicare visit doesn't include). I suppose it could be accurately billed as a Welcome to Medicare visit, since it met all that criteria. But as for the time spent doing more than what is required for a Welcome to Medicare visit, do doctors generally do more than what is required by the billing code without the expectation of being compensated for that time? Are they even allowed to do that, or does that change the nature of the visit and therefore the billing code, turning it into something other than a Welcome to Medicare visit?

The problem is that Medicare specifically excludes routine physical exams from coverage, and a lot of people don't realize it and even those who do don't think it's right for routine physicals not to be covered. If a person gets a routine physical exam and Medicare doesn't pay for it, it's not a coding problem. The problem is that a routine physical isn't covered by Medicare, and changing the coding to match the desired result (coverage by Medicare) seems pretty sketchy.

 

[Pluperfect]

Yes. You no longer get ordinary annual physicals under Medicare.

Were they ever covered? I haven't looked at what the law said when it was enacted, but I generally trust what the Kaiser Family Foundation reports:

When the Medicare program was established more than 50 years ago, its purpose was to cover the diagnosis and treatment of illness and injury in older people. Preventive services were generally not covered, and routine physical checkups were explicitly excluded, along with routine foot and dental care, eyeglasses and hearing aids.

https://khn.org/news/medicare-covers-wellness-visit-not-annual-physical/

 

[Koolau]

My doc always makes it crystal clear that it is the Medicare Annual Wellness visit. Apparently they always code it correctly. Since office help typically outnumbers docs 3 to 1, there seems no excuse for bad coding, but YMMV.

 

[MissMolly]

Were they ever covered? I haven't looked at what the law said when it was enacted, but I generally trust what the Kaiser Family Foundation reports:

https://khn.org/news/medicare-covers-wellness-visit-not-annual-physical/

No. You misunderstood me. She was getting physicals that were covered when on regular insurance (pre-Medicare) but those physicals are no longer covered since she is on Medicare.

 

[Bamaman]

Look to the Medicare early "wellness check" to be essentially a mini-physical.

The most important part of health maintenance is a full chemical blood analysis because you need to know if any of the numbers are out of range.

The big killer is lung cancer, and so often people accept a hacking cough to be "normal" or the result of post nasal drip. So many people don't get their yearly chest x-ray, and they are Type IV terminal before they even know they have lung cancer. (We lost 2 friends to lung cancer last year.)

I'm Type II diabetic, and I have to go to the diabetic doctor quarterly for a blood test. If I didn't go quarterly, Medicare wouldn't pay for my insulin pump, insulin and supplies.

 

[Marita40]

Does the Wellness check for Medicare cover the "full chemical blood analysis" mentioned above? I thought it did not. I did not ask for one last year but will do so if covered.

 

[harllee]

Look to the Medicare early "wellness check" to be essentially a mini-physical.

The most important part of health maintenance is a full chemical blood analysis because you need to know if any of the numbers are out of range.

The big killer is lung cancer, and so often people accept a hacking cough to be "normal" or the result of post nasal drip. So many people don't get their yearly chest x-ray, and they are Type IV terminal before they even know they have lung cancer. (We lost 2 friends to lung cancer last year.)

I'm Type II diabetic, and I have to go to the diabetic doctor quarterly for a blood test. If I didn't go quarterly, Medicare wouldn't pay for my insulin pump, insulin and supplies.

Yearly chest X-ray? I have never had a chest X-ray. Of course I have never smoked and don't have a cough. I looked it up--chest X-rays are not recommended unless you are at high risk for lung cancer, meaning you smoke or use to smoke.

 

[RetMD21]

Medicare will cover low dose CT scan for eligible folks. They won't pay for useless random blood tests unless miscoded by the provider. I think the last time annual CXR was recommended was in the 1960s

https://www.cancer.org/treatment/fi...t=As part of the pelvic,in the past 36 months.

 

[braumeister]

Funny (sad) story. When I was seeing a new young doctor back in the 90s, he gave me a chest X-ray every year because I had been a smoker in my youth.

One year he didn't do that and I asked him why. It was because the machine had died and he felt it was too expensive to buy a new one. His comment was "Really a shame, because that was such a nice profit center."

 

[pacergal]

I think it depends on your coverage.
We have Medicare Advantage with Kaiser. Physicals are covered for us, at least they have been so far.

 

[RetMD21]

Funny (sad) story. When I was seeing a new young doctor back in the 90s, he gave me a chest X-ray every year because I had been a smoker in my youth.

One year he didn't do that and I asked him why. It was because the machine had died and he felt it was too expensive to buy a new one. His comment was "Really a shame, because that was such a nice profit center."

He missed the class on things that you aren't supposed to say out loud. Even in the 90s it was hard to get a CXR paid by insurance without miscoding

 

[Rianne]

If you're already seeing a doctor for a previous illness, kidney disease, or cancer, the follow-up yearly or bi-yearly visits are covered, right? There are blood tests that go along with those DX.

For instance, when you go on Medicare, do they see you have pre-existing conditions and allow for those follow-up visits? Do you have to wait for symptoms to be covered? Like my hip hurts, I need a hip replacement? Maybe I'm overstating that situation, but how can they not cover health maintenance?

 

[Teacher Terry]

My doctor has me come in yearly for a checkup but I have HBP and she orders blood work. Medicare always pays.

 

[RetMD21]

My doctor has me come in yearly for a checkup but I have HBP and she orders blood work. Medicare always pays.

Medicare will cover everything medically necessary for treatment. Your doctor can also do and bill for a wellness visit if they complete the elements.