Medicare’s Costly Confusion

By January 13, 2023 Medicare

Kaiser Health News (KHN) recently published a story about Medicare beneficiary Beverly, who had scheduled her annual physical exam. Expecting Medicare would cover the checkup, Beverly was shocked when she received the bill from her doctor’s office. She was not aware (apparently neither was the doctor’s office!) that Medicare does not cover annual physicals. Many people, especially those new to Medicare, do not know which services are and are not covered. It is an important reminder for all Medicare beneficiaries to review their Medicare plan and understand which services are covered to avoid unexpected bills.

One contributing factor is confusion about the differences between a Medicare Annual Wellness Exam vs. an Annual Physical Exam. This confusion can be a major challenge for providers as well. Healthcare providers should be able to explain the differences between these two types of exams to their patients. Providers should also ensure that their coding and billing practices are accurate to avoid denials and other issues that can delay reimbursement payments. It’s clear that more education and effort is needed on all fronts.

To understand the differences between traditional physicals and Medicare’s annual exams here’s a brief summary of the key differences between these two types of exams and what a “Welcome to Medicare Visit” is:

What is a Welcome to Medicare Visit?

The Welcome to Medicare visit is a one-time checkup that is covered by Medicare. Also known as an Initial Preventive Physical Exam (IPPE). It has to take place within the first 12 months of signing up for Medicare Part B. During this visit, your doctor will review your medical and prescription history, discuss your current health, and help you create a plan for preventative screenings.

What is Annual Physical Exam?

A physical exam that (IS NOT COVERED BY MEDICARE) is a routine checkup with your doctor to review your overall health and usually done annually. It usually includes a review of your medical history, a physical exam, and a discussion of any health concerns or preventive measures you may need. If you as a Medicare beneficiary are booking a physical exam and your provider is providing preventative services that fall outside of Medicare’s allowed

billing, Medicare will not cover it and you’ll be subject to Medicare Part B’s deductible and coinsurance, resulting in out-of-pocket charges that you will be responsible for paying.

So now as to why Medicare does not cover annual physical exams, they are not considered medically necessary services. However, there are some preventive services that are covered, such as annual wellness visits, flu shots, and certain screenings. You can check with your doctor or insurance provider to find out which preventive services are covered.

What is an Annual Wellness Visit?

The Annual Wellness Visit (AWV) is an annual appointment that is covered by Medicare Part B. During this visit, your doctor will review your health history, get an update on any changes in your health, review your medications, and discuss any preventive screenings or tests that you may need. The AWV is also a great time to talk to your doctor about any health issues or concerns you may have.

When you call to make an appointment for an Annual Wellness Visit, it’s really important to be sure to use the phrase “Annual Wellness Visit”. That way, you can make sure that you are booked for the type of appointment that will be covered. This visit is different from a physical, so making sure you mention the right phrase will help you get the appointment you need. If you have any questions, don’t hesitate to ask the person you are speaking to.

It’s always a good idea to consult your doctor or insurance provider before making any decisions related to your health care. They can provide you with accurate information about what is covered and what isn’t, so you can make sure you’re getting the best care possible.

“Looking after my health today gives me a better hope for tomorrow.”

– Anne Wilson Schaef

We suggest looking into resources like our blog, which provides helpful tips on understanding the differences between wellness and physical exams. You can also find more information about Medicare coverage on the Medicare website https://www.medicare.gov

We hope this information has been helpful! Feel free to reach out if you have any other questions or need additional information. Have a great day!

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