When Beverly Dunn called her new primary care doctor’s office to schedule an annual checkup, she assumed her Medicare coverage would pick up most of the tab.
The appointment seemed like a routine physical, and she was pleased that the doctor took his time examining her.
That is, until she got the bill for $400.
Dunn, 69, called the doctor’s office assuming there was a billing error. But it was no mistake, she was told. Medicare does not cover an annual physical exam.
The Austin, Texas resident was tripped up by Medicare’s confusing coverage rules. Federal law prohibits the health care program from paying for annual physicals, and patients who get them may be on the hook for the entire amount. But beneficiaries pay nothing for an “annual wellness visit,” which the program covers in full as a preventive service. An annual physical typically involves an exam by a doctor along with bloodwork or other tests. The annual wellness visit generally doesn’t include a physical exam, except to check routine measurements such as height, weight and blood pressure. 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.
“It’s very important that someone, when they call to make an appointment, uses those magic words, ‘annual wellness visit,’” said Leslie Fried, senior director of the Center for Benefits Access at the National Council on Aging. Otherwise, “people think they are making an appointment for an annual wellness visit and it ends up they are having a complete physical.”
At the first wellness visit, patients review their risk-assessment and medical history with a doctor, nurse practitioner or physician assistant. The clinician will typically create a schedule for the next decade of mammograms, colonoscopies and other screenings and evaluate people for cognitive problems and depression as well as their risk of falls and other safety issues. At subsequent wellness visits, the doctor and patient will review these issues and check basic measurements.
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. Medicare generally won’t cover lab work, such as cholesterol screening, unless it’s tied to a specific medical condition.
Over the years, preventive services have gradually been added to the program, and the Affordable Care Act established coverage of the annual wellness visit. Medicare beneficiaries pay nothing as long as their doctor accepts Medicare. The ACA requires insurers to provide coverage, without a copay, for a range of preventive services, including immunizations. But if a visit goes beyond prevention, the patient may encounter charges.
Adding to potential confusion is the fact that Medicare Part B beneficiaries can opt for a “Welcome to Medicare” preventive visit within the first year. Meanwhile, some Medicare Advantage plans do cover annual physicals for their members free of charge.
Beneficiaries may not be the only ones who are unclear about what an annual wellness visit involves. A recent study published in the journal Health Affairs found that just over half of the medical practices with eligible Medicare patients didn’t offer the annual wellness visit option.
When Dunn called the doctor’s office about the $400 bill, she said, the staff told her she had signed papers agreeing to pay whatever Medicare didn’t cover and Dunn doesn’t dispute that.
“There were lots of papers that I signed,” she said. “But nobody told me I would get a bill for $400. I would remember that.”
In the end, the clinic waived all but $100 of the charge, but warned her that next year she’ll have to pay $300 if she wants an annual physical with that doctor. If she comes in just for an annual wellness visit, she’ll be seen by a physician assistant.
“This whole thing was so 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.”
For a full explanation of the parameters of a wellness visit, go to www.medicare.gov/coverage/yearly-wellness-visits, or call the Michigan Medicaid/Medicare Assistance Program at 800.803.7174.
*Reprinted with permission from Kaiser Health News