On more than one occasion, I have received a call from a client fairly new to Medicare concerned about a bill. In one case, a client went for an annual physical at his Family Doctor’s office and was shocked to find his visit was not covered by Medicare. In addition, he stated his doctor recommended a Tetanus booster shot since he hadn’t had one in over ten years. He later got a bill for over $300. So how can this be and what, if any, preventive care does Medicare cover? Here is a look at what is covered and what to look for if you get an unexpected bill!
If You Get a Bill, Don’t Panic
The first piece of advice I give clients is not to panic if they get a bill they are not expecting, or the amount looks off. Sometimes the provider will bill the patient even before billing Medicare or the insurance company. There are also other instances where the coding is incorrect, or the bill just simply has errors on it. So, if the amount looks strange or you didn’t think you would get a bill, first look at the date of service, type of service and whether Medicare or insurance has paid anything yet. Also, don’t forget that you may have a medical deductible to meet at the beginning of each year. If so, you owe that first before Medicare or insurance pays. Lastly, you may need to consider the service may not actually be covered by Medicare because it is preventive or not medically necessary according to Medicare guidelines.
Preventive Care: Annual Physicals
Medicare does cover a lot of preventive care, exams, and vaccinations. When you first enroll in Medicare, there is a one time ‘Welcome to Medicare’ full physical covered within twelve months. However, after that, Medicare does not cover annual physicals with your Family Doctor. There is something called a ‘Wellness Visit’ that is covered, but it is not the same thing as a physical. And again, there are billing codes distinguishing the two. So, in the example above, my client was charged for what was coded as an ‘Annual Physical’ after he was already on Medicare for over a year. I recommended he talk to his doctor about coding his visit as a ‘Wellness Visit’, if appropriate.
Preventive Care: Vaccines – Part B or Part D
Medicare does cover most preventive vaccines. There have been recent changes and advancements in this area as well. Beginning in 2023, patients with Medicare Part D plans will pay nothing out of pocket for adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). In addition, Medicare Part B covers flu, pneumonia, COVID 19, Hepatitis B and any vaccine to treat an injury or exposure (ie. Tetanus when you step on a rusty nail). Back to the example above, my client’s Tetanus booster shot was not covered by Part B because it was preventive. However, if the claim would have been submitted to his Part D plan, it would have been covered. Shingles has also been added as a preventive covered vaccine under Part D. Medicare rules are constantly changing. It is hard for Doctor’s offices to keep up. That change for preventive vaccines being covered by Part D occurred in 2023 as part of the Inflation Reduction Act.
When Preventive Becomes Diagnostic
Here is another scenario to watch out for and may surprise you with a bill. Something that starts as a covered preventive screening may quickly turn to a diagnostic test. For example, you are getting a colonoscopy as a preventive exam but during the exam, the Gastroenterologist performing it finds polyps and removes them for testing. This exam now becomes a diagnostic procedure, not a preventive screening. You may now get a bill for some of the cost depending on your plan (ie. deductible, copays, etc.). It is still covered but may have additional diagnostic fees when if it were purely preventive, there would be no fee.
Helpful Resources
https://www.medicare.gov/coverage/preventive-screening-services
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
QUOTE OF THE DAY:
“The doctor of the future will give no medicine, but will instruct his patients in care of the human frame, in diet, and in the cause and prevention of disease.” – Thomas Edison
