Medicare coverage

[Koolau]

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.

DW had to have an X-ray for sudden pain (turned out to be gastritis.) But the X-ray covered the lung area and it saved her life. She was never a smoker and had a non-smoking related tumor in her lung. We had just gotten kids at the time. It was a very close one.

I've always been concerned about too much x-radiation, but, keep in mind, a simple chest X-ray isn't much more radiation that one receives on an airline flight at altitude. So I wouldn't avoid them just to avoid them but YMMV.

 

[Dash man]

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?

Yes, when I had my Welcome to Medicare visit last year, my doctor ordered all the regular lab work because of my existing conditions and I was not billed for any of them once I met my Part B deductible. I go again later this month.

 

[Teacher Terry]

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

Wellness visits are a joke and I won’t participate. I get a yearly physical with my yearly visit to my doctor.

 

[harllee]

Wellness visits are a joke and I won’t participate. I get a yearly physical with my yearly visit to my doctor.

Terry, how much are you charged out of pocket for your yearly physical?

 

[RetMD21]

Wellness visits are a joke and I won’t participate. I get a yearly physical with my yearly visit to my doctor.

You are apparently responding to my comment but I don't think you understand the difference between preventive visits and treatment/disease management. Your visit is most likely coded for treatment of your medical condition.

 

[Teacher Terry]

Ret MD , I totally understand the difference because I worked years ago paying health insurance claims for a big company. I realize the doctor is coding for my BP and then giving me a physical that I don’t have to pay for.

 

[youbet]

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

I don't think your doc has you come in for a "checkup." She has you come in for tests necessary to monitor your BP and related conditions that cause it to be high. If she had you come in for a "checkup" and coded it as a "checkup" then Medicare wouldn't pay.

I'm in a similar situation. No annual checkup. But, at 75, I have enough conditions that need monitoring that doc can order a full blood workup and EKG and code the tests as monitoring existing conditions.

 

[Teacher Terry]

You bet, yes obviously that’s the case. How things are coded have always been the way to get claims paid.

 

[misanman]

Are we saying that some doctors will fraudulently code services because otherwise Medicare wouldn't pay for them?

 

[CardsFan]

Are we saying that some doctors will fraudulently code services because otherwise Medicare wouldn't pay for them?

I think we are saying that some doctors treat their patients correctly, code correctly, and get paid correctly.

 

[Katsmeow]

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?

They cover your medical conditions whether pre-existing or not. They don't cover an annual physical that is done just because a year is up and it is time for one. Basically you need to have a medical reason to come to the doctor. That might be monitoring high cholesterol, for example, where I might see the doctor and he might run some lab work, etc. Honestly, DH has been on Medicare 10 years and he goes to the doctor when he needs to go to the doctor. Medicare does cover lots of preventative care to be clear. Just not an annual physical. So, for example, Medicare covers an annual mammogram for me. But, if I needed an mammogram sooner than once a year then there would need to be a reason for it.

Are we saying that some doctors will fraudulently code services because otherwise Medicare wouldn't pay for them?

I don't think anyone is saying that. My perception is that some doctor's offices really are not that knowledgeable about Medicare coding and what Medicare requires so they just aren't that careful to properly code stuff. For patients on private insurance there might be two things that both are covered (assume the charge is the same) and the person submitting the claim is not always that careful on how they submit it. But, for a patient on Medicare one thing might be covered and the other not. So they need to get it right.

 

[RetMD21]

Wellness visits are a joke and I won’t participate. I get a yearly physical with my yearly visit to my doctor.

These components of the wellness visits are not a joke:

A review of your medical and family history.
A review of your current providers and prescriptions.
Height, weight, blood pressure, and other routine measurements.
Personalized health advice.
A list of risk factors and treatment options for you.
A screening schedule (like a checklist) for appropriate preventive services. Get details about coverage for screenings, shots, and other preventive services.
Advance care planning
Your provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease.

 

[Koolau]

I think we are saying that some doctors treat their patients correctly, code correctly, and get paid correctly.

Yes, and I think this has more to do with their competence rather than their ethics (for which I assume the best until I see otherwise.)

 

[Koolau]

Wellness visits are a joke and I won’t participate. I get a yearly physical with my yearly visit to my doctor.

As some others have suggested, Wellness visits are a standard evaluation that CAN give doctors a road map for further testing or evaluation. They are not always fruitful - and I consider that a good "waste" of HC dollars. It's nice when the doc finds nothing "suspicious."

The standardization insures that nothing is missed, though being interviewed by a doc with just a stethoscope and a lap top was initially off-putting. I see now how it could be life saving.

It seems a "joke" at first to someone like me who sees my doc 3 or 4 times/year for stuff he is following. IOW, why do the wellness since most is covered throughout the year? But the completeness of the Wellness exam is it's key to success IMO. Naturally, YMMV.

 

[Pluperfect]

Are we saying that some doctors will fraudulently code services because otherwise Medicare wouldn't pay for them?

Maybe. An awful lot of people here report getting annual physicals paid for by Medicare, even though annual physicals aren't covered by Medicare. And if people ask here why their annual physical wasn't covered, they're told it's because it was improperly coded, when there's no code for a routine physical exam because it's never covered.

Something must be going on to get Medicare to pay for these annual physicals. Maybe it's the patient complaining to the doctor's office, and the doctor's office changing the coding to a wellness visit even though what was actually performed was an annual physical. Fraud is a strong word, but possibly applicable.

Or maybe what someone here is calling an annual physical isn't actually an annual preventive physical, but instead a visit for an existing condition, like the example CardsFan gave about visits related to monitoring maintenance drugs for high blood pressure or high cholesterol. They're covered.

But the OP in this thread asked why his wife's "annual check up" wasn't covered, and that sounds like an actual physical exam, preventive in nature, and not just the "wellness" questions that are part of a wellness visit or welcome to Medicare visit. And someone responded that it was probably coded wrong, which I doubt is the case, but don't know for sure because the OP never came back and clarified what services were performed during that visit.

Someone else complained that even though he'd ask for an annual wellness exam, his doctor would code it as a physical. What's not clear, again, is what the doctor did during the visit, because it's possible it really was an annual physical exam and not a wellness exam (as defined by Medicare). If that were the case, the doctor wasn't coding it improperly; it may not match what the poster asked for, but I think what matters is what is actually done during the visit.

 

[Teacher Terry]

These components of the wellness visits are not a joke:

A review of your medical and family history.
A review of your current providers and prescriptions.
Height, weight, blood pressure, and other routine measurements.
Personalized health advice.
A list of risk factors and treatment options for you.
A screening schedule (like a checklist) for appropriate preventive services. Get details about coverage for screenings, shots, and other preventive services.
Advance care planning
Your provider will also perform a cognitive assessment to look for signs of dementia, including Alzheimer’s disease.

Ret MD, I have had the same doctor for 25 years. I see her yearly unless I am sick and then go more frequently. My doctor knows me well and trusts me. I don’t need a cognitive assessment and actually find some of the things that the government decides at a certain age is their business as insulting. My doctor uses MyChart and I know when all my preventive tests are due and then decide which I will do. Luckily the days of blindly following whatever a doctor says are gone.

 

[isisdave]

I can't imagine anyone over 65 who doesn't have something that could be coded as a diagnosis that would thus make an office visit payable. Monitoring of any chronic meds for BP or cholesterol ought to cover about 95 percent of us. The rest of us have some skin glitch that needs checking.

 

[RetMD21]

Ret MD, I have had the same doctor for 25 years. I see her yearly unless I am sick and then go more frequently. My doctor knows me well and trusts me. I don’t need a cognitive assessment and actually find some of the things that the government decides at a certain age is their business as insulting. My doctor uses MyChart and I know when all my preventive tests are due and then decide which I will do. Luckily the days of blindly following whatever a doctor says are gone.

Oh, ok. Reviewing meds and medical history isn't important if you don't have other doctors involved and you are getting your blood pressure checked. Rather than a "joke" I'd say that some of the items aren't applicable to you. And of course you get your "physical" as part of management of your BP. YMMV

 

[Teacher Terry]

I see a cpap doctor every few years when they make me come in if I want new supplies and no medication is prescribed. I see my allergist yearly for my allergy drops and they prescribe medication for my asthma. It’s all on MyChart and my primary doctor will also prescribe the asthma medication. I am really holding firm about not being on more than 4 medications and would only consider taking something else if it was a serious condition. Any time I see my primary the first thing they do is review my medications. I assumed all doctors do this.

 

[Koolau]

I can't imagine anyone over 65 who doesn't have something that could be coded as a diagnosis that would thus make an office visit payable. Monitoring of any chronic meds for BP or cholesterol ought to cover about 95 percent of us. The rest of us have some skin glitch that needs checking.

Heh, heh, and just wait until you are 75! If you don't have something coded by then - there's something wrong with you!

 

[davidfin]

As I understand Medicare, the only annual exam is a light weight meeting with your doctor called a wellness visit. Intended to assess if you are having physical or cognitive issues that might require additional services. It’s not a physical.

 

[Dash man]

As I understand Medicare, the only annual exam is a light weight meeting with your doctor called a wellness visit. Intended to assess if you are having physical or cognitive issues that might require additional services. It’s not a physical.

I have my wellness visit at the end of the month. I already have the lab slip for all my bloodwork that she does every six months. My nephrologist has also given me lab work to have done at the same time. They’ll do whatever is needed for monitoring existing conditions.

 

[garyt]

Probably a dumb question but if Medicare doesn't cover a physical, would your medical plan cover it?

 

[RetMD21]

Probably a dumb question but if Medicare doesn't cover a physical, would your medical plan cover it?

The supplement won't but a Medicare Advantage might

If you have any sort of medical problem the doctor can do a physical based on that but He/She might prefer to bill for something not covered by Medicare to enhance revenue

 

[Koolau]

As I understand Medicare, the only annual exam is a light weight meeting with your doctor called a wellness visit. Intended to assess if you are having physical or cognitive issues that might require additional services. It’s not a physical.

My first wellness visit, the doc walked in with his lap top. I asked him if that was his "Tri-corder?" He either didn't watch Star Trek reruns or just didn't have a sense of humor. I replaced him soon after. YMMV