When Beverly Dunn called her new primary care doctor's office last November to schedule an annual checkup, she assumed her Medicare coverage would get most of the tab.
The appointment seemed like a routine physical, and she was pleased that the doctor spent considerable time with her.
Until she got the balance: $400.
Dunn, 69, called the doctor's office assuming there is a billing error. But it was no mistake, she was told. Medicare does not cover an annual physical exam.
Dunn, of Austin, Texas, was tripped up by Medicare's confusing coverage rules. Federal law prohibits the care program from spending money on annual physicals, and patients who get them might be on the hook for the entire amount. But beneficiaries pay nothing to have an “annual wellness visit,” which the program covers in full as a preventive service.
“It's extremely important that somebody, when they call to make a scheduled appointment, uses those magic words, 'annual wellness visit,'” said Leslie Fried, senior director of the Center for Benefits Access in the National Council on Aging. Otherwise, “people think they are making a scheduled appointment to have an annual wellness visit and it ends up they are having a complete physical.”
An annual physical typically involves a test with a doctor together with bloodwork or any other tests. The annual wellness visit generally doesn't include a physical exam, except to check on routine measurements for example height, weight and blood pressure level.
The focus of the Medicare wellness visit is on preventing disease and disability by coming up with a “personalized prevention plan” for future medical issues based on the beneficiary's health and risk factors.
At their first wellness visit, patients will frequently complete a risk-assessment questionnaire and review their family and personal medical history using their doctor, a nurse practitioner or physician assistant. The clinician will typically produce a agenda for the next decade of mammograms, colonoscopies along with other screenings and evaluate people for cognitive problems and depression as well as their risk of falls and other issues of safety.
They could also talk about advance care planning with beneficiaries to create decisions by what type of medical treatment they want in the future if they can't decide for themselves.
At subsequent annual wellness visits, the doctor and patient will review these problems and appearance basic measurements. Beneficiaries can also receive other covered preventive services such as flu shots at those visits at no cost.
When the Medicare program was established more than Half a century ago, its purpose ended up being to cover diagnosing and management of illness and injury in older people. Preventive services were generally not covered, and routine physical checkups were explicitly excluded, together with routine foot and dental hygiene, eyeglasses and hearing aids.
Over time, preventive services have gradually been added to this program, and also the Affordable Care Act established coverage from the annual wellness visit. Medicare beneficiaries pay nothing so long as their doctor accepts Medicare.
However, if a wellness visit veers past the bounds from the specific covered preventive services into diagnosis or treatment – whether in the urging of the doctor or even the patient – Medicare beneficiaries will typically owe a copay or any other charges. (This can be an issue when individuals in private plans get preventive care, too. And it can affect patients of every age group. The ACA requires insurers to provide coverage, without a copay, for a selection of preventive services, including immunizations. But if a visit goes beyond prevention, the individual may encounter charges.)
And to add more confusion, Medicare beneficiaries can opt for a “Welcome to Medicare” preventive visit within the first year of joining Medicare Part B, which covers physician services.
Meanwhile, some Medicare Advantage plans cover annual physicals for his or her members totally free.
Many patients want their doctor to evaluate or treat chronic conditions like diabetes or arthritis in the wellness visit, said Dr. Michael Munger, who chairs the board from the American Academy of Family Physicians. But Medicare generally won't cover lab work, for example cholesterol screening, unless it's tied to a specific medical problem.
At Munger's practice in Overland Park, Kan., staffers routinely ask patients who are available in for a wellness visit to sign an “advance beneficiary notice of noncoverage” acknowledging that they understand Medicare may not purchase a few of the services they receive.
As long as beneficiaries comprehend the coverage rules, it's not generally a problem, Munger said.
“They don't wish to return for any separate visit, so they just understand that there might be extra charges,” he explained.
Beneficiaries might not be the only ones who're undecided about how much of an annual wellness visit involves, said Munger. Providers may be placed if they think it's yet another task that contributes to their paperwork.
A recent study published within the journal Health Affairs discovered that in 2021 approximately 1 / 2 of practices with eligible Medicare patients didn't offer the annual wellness visit. That year, 18.8 percent of eligible beneficiaries received a yearly wellness visit, case study found.
Primary care physicians generally want to see their sufferers at least once annually, Munger said, however it doesn't have to be for a complete physical exam.
A wellness visit or even a visit for any ankle sprain could give doctors an opportunity to sign in with patients and make sure they're on the right track with preventive and other care, Munger said.
When Dunn known as the doctor's office concerning the $400 bill, she said, employees informed her she had signed papers agreeing to pay whatever Medicare didn’t cover.
Dunn doesn't dispute that.
“There were plenty of papers which i signed,” she said. “But nobody told me I'd obtain a bill for $400. I'd keep in mind that.”
In the end, the clinic waived basically $100 from the charge, but warned her that the coming year she'll need to pay $300 if she would like a yearly physical with this doctor. If she is available in just for a yearly wellness visit, she'll be seen with a physician assistant.
Dunn is considering her options. Sherrrd like to stay together with her new doctor, who came recommended, and she's worried she might have trouble finding a different one just as good who accepts Medicare. But $300 seems steep to her for a checkup.
“This event am stressful for me,” she said. “I lost sleep for nights. It's not that I couldn't afford it, but it didn't seem right.”