When Beverly Dunn called her new GP in November for an annual checkup, she figured her Medicare coverage would get the bulk of the tab.
The appointment seemed routine, and she was glad about it. The doctor spent a lot of time with her.
Until she got the bill: $ 400.
The 69-year-old Dunn called the doctor's office, assuming that there was a billing error. But it was not a mistake, she was told. Medicare does not cover a yearly physical exam.
The resident of Austin was stumbled upon by the confusing provisions of Medicare. The federal law prohibits the health program from paying the annual costs, and the patients who receive them may be on the hook for the entire amount. However, the beneficiaries do not pay anything for an "annual wellness visit", which the program fully covers as a precautionary benefit.
"It is very important that someone, when making an appointment, uses these magic words, the annual wellness visit," said Leslie Fried, senior director of the Center for Social Benefits at the National Council on Aging , Otherwise, "people say they're going to make an appointment for an annual wellness visit, and they end up with a complete physical condition."
An annual physical exam usually involves a medical checkup along with blood tests or other exams. The annual wellness visit generally does not include physical examinations except to check routine measurements such as height, weight and blood pressure.
The focus of the Medicare wellness visit is on disease prevention and disability by developing a "personalized physician" prevention plan for future medical issues based on the beneficiary's health and risk factors.
During their first wellness visit, patients often complete a risk assessment questionnaire and review their relatives and personal history with their doctor, nurse or physician assistant. The clinician will typically set a timeline for the next decade of mammograms, colonoscopy, and other checkups, and will examine people for cognitive problems and depression as well as their risk of falling and other safety issues.
You may also talk about planning care with the beneficiaries to decide what kind of medical treatment they will want in the future if they can not make decisions for themselves.
At subsequent annual wellness visits, physician and patient will review these issues and review basic measurements. Beneficiaries may also receive other covered preventive services such as flu vaccines free of charge during these visits.
When the Medicare program was established more than 50 years ago, it should be about diagnosing and treating diseases and injuries affecting older people. Preventive services were generally not recorded, and routine physical examinations, foot and dental care, glasses and hearing aids were expressly excluded.
Over the years, preventive services and the Affordable Care Act have been progressively added. Established coverage of the annual wellness visit. Medicare beneficiaries will not pay as long as their doctor accepts Medicare.
However, if a wellness visit goes beyond the boundaries of specific prevention services to diagnosis or treatment – whether at the urging of the doctor or the patient – Medicare beneficiaries can typically experience a co-pay or other fees.
(This can be a problem if people in private plans also receive preventative care, and they can affect patients of all ages.) The ACA requires insurers to provide coverage without co-pays for one area preventive measures, including vaccinations, however, if a visit goes beyond prevention, the patient can file an indictment.)
And to add to the confusion, Medicare beneficiaries can choose a "Welcome to Medicare" pre-visit within the first period Year of accession to Medicare, Part B, where medical services are provided.
Some Medicare Advantage plans are free of annual membership fees.
Many patients want their doctoral degree "During the wellness visit to evaluate or treat chronic conditions such as diabetes or arthritis," said Michael Munger, chairman of the board of the American Academy of Family Physicians. In general, however, Medicare does not treat lab work, such as For example, cholesterol screening if not bound to a specific medical condition.
At Mungers practice in Overland Park, Canada, employees regularly ask patients who come for a spa visit to sign a "non-coverage recipient notification" recognizing that Medicare may not be paying for some of the services they provide ,
As long as the recipients understand the coverage rules, this is generally not a problem, Munger said.
They do not want to come back for a separate visit, so they just understand that there might be extra costs, "he said.
Beneficiaries may not be the only ones who are not sure what an annual wellness visit involves, Munger said. Providers may be deferred if they feel that this is just another task that increases their paperwork.
A recent study published in the journal Health Affairs found that in 2015, just over half of the practices with eligible Medicare patients did not offer the annual health visit. This year, 18.8 percent of eligible beneficiaries received an annual wellness visit, according to the analysis.
General practitioners want to visit their patients at least once a year, Munger said, but it's not a complete physical exam
A spa visit or even a visit to a sprained ankle could give doctors the opportunity to connect with patients Ensuring that they are on the right path with preventive and other treatment, Munger said.
Dunn said when she called In the doctor's office about the $ 400 bill, the staff told her that she had signed papers committed to paying for Medicare.
Dunn does not deny that.
"There were many papers I signed." She said. "But no one told me I would get a $ 400 bill. I would remember that.
In the end, the clinic refused to pay anything but $ 100 to the prosecution, but warned her that she would have to pay $ 300 next year if she wanted to have an annual doctor's visit to that doctor. If she only comes for an annual wellness visit, she is seen by a medical assistant.
Dunn considers what options she has. She would like to stay with her new doctor, who was highly recommended, and she worries that she may have difficulty finding another doctor to accept Medicare. But $ 300 for them seems to be steep.
"The whole thing was so exhausting for me," she said. "I did not sleep at night. I could not afford it, but it did not seem right.
Kaiser Health News is a non-profit news service that deals with health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.