Medicare annual physical vs wellness visit

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dm200
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Medicare annual physical vs wellness visit

Post by dm200 »

Article about something often discussed here -

https://www.washingtonpost.com/national ... e261035fcc
graeme
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Re: Medicare annual physical vs wellness visit

Post by graeme »

Similarly, my employer based insurance is a high deductible plan where yearly physicals are supposedly free. After calling the insurance and my doctor's office to see how that worked, they said a physical would be fully covered if the doctor found no diagnosis (i.e. no codes) and also didn't order any blood work. If anything was recorded during the 'physical', it would be considered a normal visit and my cost would start at $139. The more discussed at any doctor visit, the more codes they could record and the higher my cost would be.
toofache32
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Re: Medicare annual physical vs wellness visit

Post by toofache32 »

This entire concept was flawed from the beginning. Look for problems, but don't address them. That requires another visit. So you end up paying anyway to get what you need.
Patients just think it's a free visit where they can get as much as they can in a single visit. It's not, and they get upset when asked to return to address their diagnoses and charges will apply. As it turns out, they get just as upset to address it the same day while charges apply.
JPM
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Re: Medicare annual physical vs wellness visit

Post by JPM »

Medicare allows one free annual "Wellness visit" but does a poor job of explaining to beneficiaries what its "Wellness visit" means. It doesn't mean having a checkup to see if you are well or not. Many doctors don 't know what it means either. I have seen gynecologists bill a routine well woman exam as a medicare "Wellness exam". The wellness visit is not a checkup or review of existing problems. It is supposed to be a set of vital signs (weight, blood pressure, pulse rate), an assessment of mental status which may be brief or not, review of the other doctors you are seeing and of the medicines you are taking, vaccination status, and a brief test of vision like reading the eye chart with the big E or just reading a sign in the office, a simple hearing check like whispering a word to you, and that is all. The clinic may update your records in regard to what meds are being used and what other doctors are being used by you. There is no general medical/health assessment and no treatment apart from administering due vaccine(s).

Most primary care offices have this service done by a PA or nurse practitioner if one is available or incorporates the data collection function into a regularly scheduled assessment and treatment visit with the doctor billed at the usual rate for such visits. The electronic record systems often have a template for "Wellness Visit" incorporating the data set described above.

On your first visit of this type, termed "Welcome to medicare visit" you can and should have a free baseline electrocardiogram made and may in some circumstances qualify to have a free screening ultrasound exam looking for an abdominal aortic aneurysm. The electrocardiogram serves as a baseline for comparison to any future electrocardiogram you may need for diagnosing a problem. Whether or not there is a change from the baseline may have an important bearing on diagnosis in your future.

When in private practice, I did not do or bill Wellness visits as I considered them a waste of my time. With established patients, most of these services were superfluous or already done incidental to routine medical care. As an employed doctor, our clinic comes under pressure from the employer to get them done. The insurers come under pressure from Medicare to get them done. Medicare wants this data set for its own purposes. Those purposes are unclear at least to me.

Dismaying that the relatively sophisticated crowd on these threads has so poor an understanding of how the medical care system and the medical insurance system work when they have so sophisticated an understanding of how the nonmedical insurance system and the financial system work. The medical and its related insurance systems change a lot over time and promise to change even faster in the coming years. The tension among advances in medical technology, rapid growth in the high needs populations, and constrained resources to pay for it all is a social problem that will inevitably require choices at a societal level. Recent (2-5 years) advances in cancer treatment are astounding in both what they make possible and in what they cost.
drawpoker
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

Yes, and it is even more screwed up than that. Apparently the physicians don't even understand the first "Welcome" visit. The exam that people are supposed to get within the 1st 12 months they start Medicare.

I thought I had made it clear when booking appt. for my "Welcome to Medicare" visit what I was seeking. Then, later, well, um, seemed like I got a pretty thorough exam by the doc at the time. Apparently not.

Weeks later, here comes the 1st quarterly Medicare Summary statement. Showing that it was denied. All of it. I was on the hook for the full freight, Medicare wouldn't cover any of it. Duh

After inquiring, turns out the reason for the denial - physician failed to perform one of the designated diagnostic tests that was on Medicare's punch list of things that had to be done (mandatory) during "Welcome" visit. Maybe the electrocardiogram thingy? Dunno. But, Just one little slip-up, and the whole thing gets trashed.

Since the fault was with the doc's office, not me, they never billed me when Medicare wouldn't pay. Just ate the charges themselves. (If they had gone back and amended the claim to make it squeaky clean, would have known that from the next Medicare mailing, so I know they didn't)

Maybe they learned something from it????
toofache32
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Re: Medicare annual physical vs wellness visit

Post by toofache32 »

These visits should be performed by nurses or assistants. Why are doctors doing these visits since there is no "doctoring" involved? An incredible waste of resources.
JPM
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Re: Medicare annual physical vs wellness visit

Post by JPM »

Helps a lot to have a template on the electronic health record that organizes the punch list for us. When medicare started insisting we get these done, our IT people put together the template then beta tested it with a few doctors. After the beta test we all got a tutorial in how to use it. That was 6-7 years ago as i recall
drawpoker
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

toofache32 wrote: Sat Mar 16, 2019 11:00 pm These visits should be performed by nurses or assistants. Why are doctors doing these visits since there is no "doctoring" involved?
Well, if you are asking about my case as posted, FYI my PCP office at the time had no licensed nurse practitioner or a P.A. on staff. (They still don't)

Given this fact - in the rural areas of the U.S. - Can you suggest just how else these stupid "Welcome to Medicare" exams could be conducted? :confused
toofache32
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Re: Medicare annual physical vs wellness visit

Post by toofache32 »

drawpoker wrote: Sat Mar 16, 2019 11:49 pm
toofache32 wrote: Sat Mar 16, 2019 11:00 pm These visits should be performed by nurses or assistants. Why are doctors doing these visits since there is no "doctoring" involved?
Well, if you are asking about my case as posted, FYI my PCP office at the time had no licensed nurse practitioner or a P.A. on staff. (They still don't)

Given this fact - in the rural areas of the U.S. - Can you suggest just how else these stupid "Welcome to Medicare" exams could be conducted? :confused
Ask Medicare. They are the ones offering this. I'm sure whoever answers the phone will be able to answer this for you.
Not sure what this has to do with your physician. Just because something is "covered" by your insurance doesn't mean every practice must be able to provide it. Especially if they don't have the infrastructure. I run a specialty medical practice and I do not offer every service in my specialty. There are TONS of services simply not available in rural areas. If an insurer offers to pay for a certain service, they should be able to tell you where those services can be obtained.
Last edited by toofache32 on Sun Mar 17, 2019 12:03 am, edited 9 times in total.
drawpoker
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

:P :P :P :P :P :P
drawpoker
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

toofache32 wrote: Sat Mar 16, 2019 11:51 pm Ask Medicare. They are the ones offering this. I'm sure whoever answers the phone will be able to answer this for you......
Er, at the risk of repeating myself - hate to do, but, um, must say ....

:P :P :P :P
drawpoker
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

toofache32 wrote: Sat Mar 16, 2019 11:51 pm
Not sure what this has to do with your physician. Just because something is "covered" by your insurance doesn't mean every practice must be able to provide it......are TONS of services simply not available in rural areas. If an insurer offers to pay for a certain service, they should be able to tell you where those services can be obtained.
Um, now addressing your edit to your post, well, um,

This is Medicare we're talking about, not BlueCross or some other private-party type insurance. Medicare is taking the position that these dumb "Welcome Visits" are a "covered" benefit.

If a doc's office says "yea" we take Medicare assignment, um, doesn't that mean patients should expect that office follows all Medicare rules/regs regarding claims procedures?

Just not getting your point with this.... :? :? :? :?
Big Dog
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Re: Medicare annual physical vs wellness visit

Post by Big Dog »

Patients just think it's a free visit where they can get as much as they can in a single visit.
There are plenty of descriptions on teh internet on what this visit is, or is not.

https://www.medicare.gov/information-fo ... tive-visit

https://www.medicareinteractive.org/get ... tive-visit


fwiw: my Family Practitioner performs these himself. Doctoring is involved in the cognitive assessments from speaking to the patient, i.e., do mental faculties seem in decline at 65...
SevenBridgesRoad
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Re: Medicare annual physical vs wellness visit

Post by SevenBridgesRoad »

JPM wrote: Sat Mar 16, 2019 10:20 pm ...On your first visit of this type, termed "Welcome to medicare visit" you can and should have a free baseline electrocardiogram made and may in some circumstances qualify to have a free screening ultrasound exam looking for an abdominal aortic aneurysm. The electrocardiogram serves as a baseline for comparison to any future electrocardiogram you may need for diagnosing a problem. Whether or not there is a change from the baseline may have an important bearing on diagnosis in your future....
I agree with most of your post, but I can't let your matter-of-fact EKG recommendation pass without pointing out it may not be that straightforward. The American College of Cardiology/American Heart Association guidelines for asymptomatic adults states that a resting EKG is probably indicated in patients with diabetes and hypertension and its usefulness in patients without these conditions isn't well established. Further, The US Preventive Service Task Force recommends against a screening EKG in adults with low risk of CHD events (there is a scoring system to determine risk). The Choosing Wisely program of The American College of Physicians in partnership with many other professional medical societies suggests the screening or baseline ECG is not useful in patients without symptoms who are low risk. You can Google an article from The American Journal of Medicine December 1991 on The Baseline Electrocardiogram. Read at least the first few paragraphs. Anyway, I know many docs still think these are of value and lots of patients want one, despite the evidence. I don't want to argue, but I did want to point that out plenty of other physicians don't think screening/baseline EKGS are valuable.

As if preventive care and screening exams are already not complicated enough, I hate to throw this EKG controversy into the mix. But I have to point out there is another, well-informed side to the EKG story. Of course, it still comes down to an individual physician and their individual patient making a decision (hopefully, an informed decision). And, I'll leave it to the readers to research (Google) the value of a screening ultrasound for AAA. (Spoiler alert: it depends...)
JPM
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Re: Medicare annual physical vs wellness visit

Post by JPM »

The medicare people probably had this same debate surrounding the decision to add the electrocardiogram to this service. They may have felt that on average a medicare patient is not a low risk patient, ergo to encourage this service.
3hrs
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Re: Medicare annual physical vs wellness visit

Post by 3hrs »

DH and I studied our Medicare options thoroughly before turning 65 last year. We selected a Medicare Advantage Plan that covers an annual physical. Thanks to previous Boglehead threads, I knew I needed to make sure the visit was coded correctly. Wow! Every step of the way I had to correct the assumptions that I had scheduled a Wellness Visit. This involved two calls to my insurer, the medical center appointment desk,and correcting the medical assistant who on the day of the physical asked me to fill out a Wellness Visit Survey. The correct information still did not reach my physician, who wanted to make sure I would not incur charges for a non covered physical. Once I explained to her I have a Medicare Advantage plan there was no problem.
toofache32
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Re: Medicare annual physical vs wellness visit

Post by toofache32 »

drawpoker wrote: Sun Mar 17, 2019 12:26 am
toofache32 wrote: Sat Mar 16, 2019 11:51 pm
Not sure what this has to do with your physician. Just because something is "covered" by your insurance doesn't mean every practice must be able to provide it......are TONS of services simply not available in rural areas. If an insurer offers to pay for a certain service, they should be able to tell you where those services can be obtained.
Um, now addressing your edit to your post, well, um,

This is Medicare we're talking about, not BlueCross or some other private-party type insurance. Medicare is taking the position that these dumb "Welcome Visits" are a "covered" benefit.

If a doc's office says "yea" we take Medicare assignment, um, doesn't that mean patients should expect that office follows all Medicare rules/regs regarding claims procedures?

Just not getting your point with this.... :? :? :? :?
Let me simplify. Not every service is offered by every doctor. For example, someone else mentioned screening ultrasounds. Many primary care docs are not gonna purchase a $50,000 ultrasound machine, especially for such a low paying group as Medicare patients.

There are certain treatments covered by insurance which doctors in my specialty are trained to provide. But I (and most) don’t offer those because they are not worth it. My point is that being in network with Medicare doesn’t mean that ALL services must be available at ALL offices. There is a huge difference in offering “health insurance” and “healthcare” which many seem to confuse.
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dodecahedron
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Re: Medicare annual physical vs wellness visit

Post by dodecahedron »

3hrs wrote: Sun Mar 17, 2019 8:08 am DH and I studied our Medicare options thoroughly before turning 65 last year. We selected a Medicare Advantage Plan that covers an annual physical. Thanks to previous Boglehead threads, I knew I needed to make sure the visit was coded correctly. Wow! Every step of the way I had to correct the assumptions that I had scheduled a Wellness Visit. This involved two calls to my insurer, the medical center appointment desk,and correcting the medical assistant who on the day of the physical asked me to fill out a Wellness Visit Survey. The correct information still did not reach my physician, who wanted to make sure I would not incur charges for a non covered physical. Once I explained to her I have a Medicare Advantage plan there was no problem.
Way too much work for me. I am happy to have a PPO MA plan with a very comprehensive regional network that has $0 copay for *all* in-network primary care visits, regardless of whether they are preventive, diagnostic, treatment, etc. All the primary care docs in my area are in-network (except for a tiny number who accept no insurance of *any* kind, not even Medicare.) So as long as I go to an in-network primary care doctor, no matter how my ¨wellness visits¨ get coded, it is zero out-of-pocket to me.

My plan gives me the right to go to any specialist who accepts Medicare for a larger copay ($50 in-network or $60 out of network) without any kind of gatekeeper referral whatsoever, so I think the zero dollar in network primary care is designed to encourage me to consult primary care docs first.
Last edited by dodecahedron on Sun Mar 17, 2019 8:34 am, edited 2 times in total.
Lynette
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Re: Medicare annual physical vs wellness visit

Post by Lynette »

I spent a lot of time on energy on this two years ago - 4 appeals as I was fed up - denied - but I was not billed. My doctor's office got the billing codes wrong as I joined Medicare when I was over 65 as I got healthcare through my employer. I have deliberately avoided going back for another wellness test because of the hassle. My doctor got dinged as he did not give me an EKG in my Welcome to Medicare. He had done it a year before when I was on my insurance through my employer. My employer required annual wellness tests for us to get a lower rate. I know my blood pressure is fine as I had minor eyelid surgery. I guess I'll have to go back one of these days but I'm extremely reluctant to do so. I take medication for high cholesterol but it seems as if blood work may not be covered. I think I am very healthy .. but I likely need to go and see my doctor to get referrals for some screenings. I have Medigap insurance and also have to pay Medicare IRMAA but I cannot even get simple tests without enormous hassle!

And I get emails from Medicare to go for a Wellness Test. The hassle will really push up my blood pressure! :shock:
montanagirl
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Re: Medicare annual physical vs wellness visit

Post by montanagirl »

I don't understand the problem. I've had wellness visits the last 4 years, always with a blood screen and it's always been covered by traditional Medicare with plan F or G.

What am I missing? Are the tests really not covered at all or are they charged to the deductible?
Lynette
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Re: Medicare annual physical vs wellness visit

Post by Lynette »

I think it depends on which side of the bed the person who does the Medicare billing wakes up on. As I have a pre-existing condition (high cholesterol), I think that the blood work may be covered but who knows? I also don't know if I need to have an EKG as it wasn't covered in the Medicare first exam. I think that this is the issue that neither Medicare or the doctors fully understand this confusing subject. I have Medigap G and have already paid the deductible for this year. I had Melanoma 25 years ago and finally decided after two years to go and have it checked again. I got chewed out by the dermatologist for not coming every year. I hate Medicare because of the confusion. I had no problem with healthcare billing when I was employed.
DetroitRick
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Re: Medicare annual physical vs wellness visit

Post by DetroitRick »

Interesting topic to me because I'm a year-and-a-half out from Medicare and trying to get an idea of what lies ahead. And I've gotten a lot a of value from recent annual physicals, so I would continue regardless of who pays (at least at my current costs). But I also notice that the 4th bullet point in the Medicare.gov link to what is covered is "Order further tests, depending on your general health and medical history". Seems like that clause is a pretty "blanket" coverage opportunity for all the standard physical stuff IF your physician feels it warranted (like cbc, ekg, etc). Assuming correct billing codes, I suppose. And I don't really get the value of the initial welcome visit - unless you are establishing a relationship with a new doctor at that time.
2015
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Re: Medicare annual physical vs wellness visit

Post by 2015 »

Big Dog wrote: Sun Mar 17, 2019 12:58 am
Patients just think it's a free visit where they can get as much as they can in a single visit.
There are plenty of descriptions on teh internet on what this visit is, or is not.

https://www.medicare.gov/information-fo ... tive-visit

https://www.medicareinteractive.org/get ... tive-visit


fwiw: my Family Practitioner performs these himself. Doctoring is involved in the cognitive assessments from speaking to the patient, i.e., do mental faculties seem in decline at 65...
Ok, so from these sites this is what is involved in a so-called Wellness Visit:
During the course of your Welcome to Medicare preventive visit, your provider should:

Check your height, weight, blood pressure, body mass index (BMI), and vision
Review your medical and social history
Review your potential for depression and other mental health conditions
Review your ability to function safely in the home and community
Provide you with education, counseling, and referrals related to your risk factors and other health needs
Give you a checklist and/or written plan with information about other preventive services you may need
I've already done all of this and much, much more. I'll skip this nonsense as I already spend entirely too much time monitoring my health as it is.
SevenBridgesRoad
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Re: Medicare annual physical vs wellness visit

Post by SevenBridgesRoad »

JPM wrote: Sun Mar 17, 2019 8:00 am The medicare people probably had this same debate surrounding the decision to add the electrocardiogram to this service. They may have felt that on average a medicare patient is not a low risk patient, ergo to encourage this service.
Yep. Makes sense.
drawpoker
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

"Doctoring is involved in the cognitive assessments from speaking to the patient, i.e., do mental faculties seem in decline at 65..."
_______________________________________________________________________________________________________

Yup, that about says it all. Everyone 65 will flunk that assessment when asked -

"Do you understand the differences between the annual physical, annual wellness exam, and the welcome visit? Please explain now concisely the Medicare-covered benefits relating to each. You may take as much time as you need."

:oops: :oops: :oops:
JPM
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Re: Medicare annual physical vs wellness visit

Post by JPM »

Nonphysicians can do the mental status evaluation using one of several available tests. The St. Louis University Mental Status test (AKA SLUMS test) is currently popular and is used in the VA system, the Mayo system, and many others. You can google it and have someone read you the questions and take it yourself if you care to do so. There are some drawing subtests in it. Takes about 15 minutes to do in clinic, longer for a slow subject. There are briefer tests as well.

The SLUMS test has a 30 point scoring system. 26 or 27-30 is normal depending on education level. Less than 20 is probable dementia and the range between 20-26 or 27 used to be called "age-related memory defect". That was deemed politically incorrect a few years ago and is now termed "mild cognitive impairment". People who score less than 12 usually have obvious dementia. Many people do better the second year as they are less nervous and know what is coming. Others show progressive decline over a few years' time. Most people in their 70s score in the mid 20s.
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dm200
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Re: Medicare annual physical vs wellness visit

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3hrs wrote: Sun Mar 17, 2019 8:08 am DH and I studied our Medicare options thoroughly before turning 65 last year. We selected a Medicare Advantage Plan that covers an annual physical. Thanks to previous Boglehead threads, I knew I needed to make sure the visit was coded correctly. Wow! Every step of the way I had to correct the assumptions that I had scheduled a Wellness Visit. This involved two calls to my insurer, the medical center appointment desk,and correcting the medical assistant who on the day of the physical asked me to fill out a Wellness Visit Survey. The correct information still did not reach my physician, who wanted to make sure I would not incur charges for a non covered physical. Once I explained to her I have a Medicare Advantage plan there was no problem.
In practice (me for eight years and DW for three), our Kaiser Medicare plan have never charged the copay for the annual wellness visit - even if we bring up a new issue. That makes things much simpler for us.

In our Kaiser plan, as well, going counter to what seems to be the trend - for office visits with our PCP, we always only see the Physician - never a Nurse Practitioner or Physicians assistant. Kaiser got rid of the Nurse practitioners in Primary care about 10 or 12 years ago in this area. My PCP is almost always available for appointments as soon as the next day, if needed. if, for some reason, she is unavailable - when needed I can get an appointment with another Physician.
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

JPM wrote: Sun Mar 17, 2019 2:01 pm ......The St. Louis University Mental Status test (AKA SLUMS test) is currently popular and is used in the VA system, the Mayo system, and many others....
Thanks, JPM :) All kidding aside now, this is great stuff to know. Very handy information to have prior to doc visit 8-)
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Re: Medicare annual physical vs wellness visit

Post by dowse »

Talk to your PCP about it. In many cases, the Wellness visit can be combined with an "Office Visit" if the patient is being treated for anything else, such as high cholesterol, high blood pressure, etc. A great many medicare recipients are already being treated for something that will justify a routine follow-up office visit. I just had my "Wellness" visit recently Because I am also being treated for other conditions, the health care provider put in a claim that inclued the Wellness visit plus another line item for an office visit. Between the two, I received what I normally used to receive during an annlual physical when covered by other insurance. As long as there is a legitimate way to justify it, there is no ethical issue, and it can be pretty much the same as a physical.
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dm200
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Re: Medicare annual physical vs wellness visit

Post by dm200 »

dowse wrote: Sun Mar 17, 2019 4:58 pm Talk to your PCP about it. In many cases, the Wellness visit can be combined with an "Office Visit" if the patient is being treated for anything else, such as high cholesterol, high blood pressure, etc. A great many medicare recipients are already being treated for something that will justify a routine follow-up office visit. I just had my "Wellness" visit recently Because I am also being treated for other conditions, the health care provider put in a claim that inclued the Wellness visit plus another line item for an office visit. Between the two, I received what I normally used to receive during an annlual physical when covered by other insurance. As long as there is a legitimate way to justify it, there is no ethical issue, and it can be pretty much the same as a physical.
I wonder (don't know) if in some medical practices, the business or insurance person might know more of such details than the Physician?
toofache32
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Re: Medicare annual physical vs wellness visit

Post by toofache32 »

dm200 wrote: Mon Mar 18, 2019 8:11 am
dowse wrote: Sun Mar 17, 2019 4:58 pm Talk to your PCP about it. In many cases, the Wellness visit can be combined with an "Office Visit" if the patient is being treated for anything else, such as high cholesterol, high blood pressure, etc. A great many medicare recipients are already being treated for something that will justify a routine follow-up office visit. I just had my "Wellness" visit recently Because I am also being treated for other conditions, the health care provider put in a claim that inclued the Wellness visit plus another line item for an office visit. Between the two, I received what I normally used to receive during an annlual physical when covered by other insurance. As long as there is a legitimate way to justify it, there is no ethical issue, and it can be pretty much the same as a physical.
I wonder (don't know) if in some medical practices, the business or insurance person might know more of such details than the Physician?
The insurance/billing person and employer will definitely know the most about this. This is an insurance issue, not a doctoring issue.
dowse
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Re: Medicare annual physical vs wellness visit

Post by dowse »

toofache32 wrote: Mon Mar 18, 2019 8:18 am
dm200 wrote: Mon Mar 18, 2019 8:11 am
dowse wrote: Sun Mar 17, 2019 4:58 pm Talk to your PCP about it. In many cases, the Wellness visit can be combined with an "Office Visit" if the patient is being treated for anything else, such as high cholesterol, high blood pressure, etc. A great many medicare recipients are already being treated for something that will justify a routine follow-up office visit. I just had my "Wellness" visit recently Because I am also being treated for other conditions, the health care provider put in a claim that inclued the Wellness visit plus another line item for an office visit. Between the two, I received what I normally used to receive during an annlual physical when covered by other insurance. As long as there is a legitimate way to justify it, there is no ethical issue, and it can be pretty much the same as a physical.
I wonder (don't know) if in some medical practices, the business or insurance person might know more of such details than the Physician?
The insurance/billing person and employer will definitely know the most about this. This is an insurance issue, not a doctoring issue.
In my case, the PCP knew about it, but it's true that the medical billing office should be the authoritative source on this.

By the way, I discovered that Medicare does not cover Tetanus shots. According to my claim, the vaccine itself was free, but the administration of it was billed at $67, which I had to pay. Other vaccines are covered in full, e.g. pneumococcal pneumonia.
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dm200
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Re: Medicare annual physical vs wellness visit

Post by dm200 »

By the way, I discovered that Medicare does not cover Tetanus shots. According to my claim, the vaccine itself was free, but the administration of it was billed at $67, which I had to pay. Other vaccines are covered in full, e.g. pneumococcal pneumonia.
Interesting.. Under my Medicare plan, I got a tetanus shot at no charge.

I have also received the original pneumonia shot and, later, the updated one. I also got the Shingrix as well. Annual flu shot. No charge for any. My PCP reviews all such immunizations with me at my annual wellness visit.
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Re: Medicare annual physical vs wellness visit

Post by dowse »

dm200 wrote: Mon Mar 18, 2019 8:32 am
By the way, I discovered that Medicare does not cover Tetanus shots. According to my claim, the vaccine itself was free, but the administration of it was billed at $67, which I had to pay. Other vaccines are covered in full, e.g. pneumococcal pneumonia.
Interesting.. Under my Medicare plan, I got a tetanus shot at no charge.

I have also received the original pneumonia shot and, later, the updated one. I also got the Shingrix as well. Annual flu shot. No charge for any. My PCP reviews all such immunizations with me at my annual wellness visit.
I have traditional Medicare, so maybe that's the difference? The tetanus shot is the only one I've had to pay anything for. Tried to get the new shingles shot(s), but currently there is a supply shortage in my area.
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dm200
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Re: Medicare annual physical vs wellness visit

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dowse wrote: Mon Mar 18, 2019 8:42 am
dm200 wrote: Mon Mar 18, 2019 8:32 am
By the way, I discovered that Medicare does not cover Tetanus shots. According to my claim, the vaccine itself was free, but the administration of it was billed at $67, which I had to pay. Other vaccines are covered in full, e.g. pneumococcal pneumonia.
Interesting.. Under my Medicare plan, I got a tetanus shot at no charge.
I have also received the original pneumonia shot and, later, the updated one. I also got the Shingrix as well. Annual flu shot. No charge for any. My PCP reviews all such immunizations with me at my annual wellness visit.
I have traditional Medicare, so maybe that's the difference? The tetanus shot is the only one I've had to pay anything for. Tried to get the new shingles shot(s), but currently there is a supply shortage in my area.
Did you independently verify that the charge for tetanus was correct for Original Medicare?

Yes - a shortage of Shingrix. At my annual wellness appointment, I made the point of asking my PCP about it. She then checked and found that I met (or she figured out how to have me meet) the priority to get them. My wife (five years younger) is still waiting. Let's hope the backlog for Shingrix goes away in 2019. Never had Shingles - but everybody I know who has had Shingles talks about how awful it is.
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Re: Medicare annual physical vs wellness visit

Post by dowse »

dm200 wrote: Mon Mar 18, 2019 8:50 am
dowse wrote: Mon Mar 18, 2019 8:42 am
dm200 wrote: Mon Mar 18, 2019 8:32 am
By the way, I discovered that Medicare does not cover Tetanus shots. According to my claim, the vaccine itself was free, but the administration of it was billed at $67, which I had to pay. Other vaccines are covered in full, e.g. pneumococcal pneumonia.
Interesting.. Under my Medicare plan, I got a tetanus shot at no charge.
I have also received the original pneumonia shot and, later, the updated one. I also got the Shingrix as well. Annual flu shot. No charge for any. My PCP reviews all such immunizations with me at my annual wellness visit.
I have traditional Medicare, so maybe that's the difference? The tetanus shot is the only one I've had to pay anything for. Tried to get the new shingles shot(s), but currently there is a supply shortage in my area.
Did you independently verify that the charge for tetanus was correct for Original Medicare?

Yes - a shortage of Shingrix. At my annual wellness appointment, I made the point of asking my PCP about it. She then checked and found that I met (or she figured out how to have me meet) the priority to get them. My wife (five years younger) is still waiting. Let's hope the backlog for Shingrix goes away in 2019. Never had Shingles - but everybody I know who has had Shingles talks about how awful it is.
Yes. I went on to the medicare.gov web site and performed the search. It does indeed say that tetanus shots are not covered. Seems very odd to met.
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Re: Medicare annual physical vs wellness visit

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Yes. I went on to the medicare.gov web site and performed the search. It does indeed say that tetanus shots are not covered. Seems very odd to me.
Odd indeed. Wonder why? Or if there are any details?

In any event, this can be very important - and (as best I recall) you only need one every ten years or so.
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Re: Medicare annual physical vs wellness visit

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dm200 wrote: Mon Mar 18, 2019 9:22 am
Yes. I went on to the medicare.gov web site and performed the search. It does indeed say that tetanus shots are not covered. Seems very odd to me.
Odd indeed. Wonder why? Or if there are any details?

In any event, this can be very important - and (as best I recall) you only need one every ten years or so.
According to medicare.gov, Part A and Part B do not cover tetanus shots but Part D generally DOES cover tetanus shots (and all shots necessary to prevent disease.)

https://www.medicare.gov/coverage/tdap-shots

From a conversation I had with a physician a few years ago, she said it can be cheaper to get vaccines from a pharmacy (where I gather Part D will cover the shot with no extra charge for administration) than from a doctor´s office (which is somehow set up to deal with Part B, but not as well with Part D?) I guess it is all about the coding.

Edited to add: since most Medicare Advantage plans (Part C) integrate Parts A,B, and D, their subscribers may have a smoother time with their getting shots covered.
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Re: Medicare annual physical vs wellness visit

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Edited to add: since most Medicare Advantage plans (Part C) integrate Parts A,B, and D, their subscribers may have a smoother time with their getting shots covered
.

Yes - our experience.
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Re: Medicare annual physical vs wellness visit

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dodecahedron wrote: Mon Mar 18, 2019 9:37 am

..... said it can be cheaper to get vaccines from a pharmacy (where I gather Part D will cover the shot with no extra charge for administration) than from a doctor´s office (which is somehow set up to deal with Part B, but not as well with Part D?)
Not necessarily. It all depends on which Part D drug plan you carry. Part D co-pays vary enormously.

In my case, it was $30 charge (total) at the doc's office to give me 10-year tetanus booster. My insurance quoted $91 :shock: :shock: co-pay amount if I got it at the pharmacy. Outrageous. They are quoting only $46 co-pay for the new Shingrex shot (if any of it ever arrives here) Makes no sense at all to me.

Admittedly, I do have a somewhat crappy Part D plan (SilverScript) Had to switch companies when former Part D insurer (First Health) was one of the ones gobbled up in the big Coventry/CVS merger. First thing they did was dump Walgreen's from their preferred network, herding everyone to start using CVS.

No CVS pharmacies within 35 miles of me :(
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Re: Medicare annual physical vs wellness visit

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drawpoker wrote: Mon Mar 18, 2019 12:43 pm
dodecahedron wrote: Mon Mar 18, 2019 9:37 am

..... said it can be cheaper to get vaccines from a pharmacy (where I gather Part D will cover the shot with no extra charge for administration) than from a doctor´s office (which is somehow set up to deal with Part B, but not as well with Part D?)
Not necessarily. It all depends on which Part D drug plan you carry. Part D co-pays vary enormously.

In my case, it was $30 charge (total) at the doc's office to give me 10-year tetanus booster. My insurance quoted $91 :shock: :shock: co-pay amount if I got it at the pharmacy. Outrageous. They are quoting only $46 co-pay for the new Shingrex shot (if any of it ever arrives here) Makes no sense at all to me.
Interesting. I am glad I was able to get my new shingles shots last summer, shortly before I turned 65 and went on Medicare. Even though I had a high deductible ACA Bronze plan at the time, the shingles shots were fully covered as preventive with zero out of pocket to me. I did notice they billed my ACA bronze plan $200 per shot (two needed).
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Re: Medicare annual physical vs wellness visit

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dm200 wrote: Mon Mar 18, 2019 12:38 pm
Edited to add: since most Medicare Advantage plans (Part C) integrate Parts A,B, and D, their subscribers may have a smoother time with their getting shots covered
.

Yes - our experience.
I think Medicare Advantage plans (Part C) have two very strong incentives to cover vaccines:

1) since they are on the hook to pay treatment costs if the member gets sick, they have an interest in preventing the disease

2) Medicare ¨rates¨ MA plans from one to five stars and highly rated plans like to promote their star ranking in their ads. One factor in the star ratings for Part C is the percentage of their members who are up to date on immunizations.

Interestingly, stand-alone Part D plans also have star ratings but the percentage of immunized subscribers is not a factor in Part D ratings, only in Part C ratings.
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Re: Medicare annual physical vs wellness visit

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dodecahedron wrote: Mon Mar 18, 2019 1:11 pm
dm200 wrote: Mon Mar 18, 2019 12:38 pm
Edited to add: since most Medicare Advantage plans (Part C) integrate Parts A,B, and D, their subscribers may have a smoother time with their getting shots covered
.
Yes - our experience.
I think Medicare Advantage plans (Part C) have two very strong incentives to cover vaccines:
1) since they are on the hook to pay treatment costs if the member gets sick, they have an interest in preventing the disease
2) Medicare ¨rates¨ MA plans from one to five stars and highly rated plans like to promote their star ranking in their ads. One factor in the star ratings for Part C is the percentage of their members who are up to date on immunizations.
Interestingly, stand-alone Part D plans also have star ratings but the percentage of immunized subscribers is not a factor in Part D ratings, only in Part C ratings.
Yes - makes sense to me as well. I believe that MA plans do and do not do certain things primarily for "good press" or patient satisfaction - irrespective of whether, objectively, there is any positive affect on improving health or reducing health risks.

Over the years, we have seen these true stories of folks who are "fake" doctors - men and women with little or no training as a doctor - but who have actually "practiced" medicine for many years. Once caught, it is interesting how many of their patients express how satisfied they were with the fake doctor.
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Re: Medicare annual physical vs wellness visit

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My doctor got dinged by Medicare as he did not give me an EKG at my first Wellness Test. I have very low blood pressure and cholesterol under control with drugs and no history of heart disease in the family. I exercise and am not obese. Last time my EKG had improved as I had started swimming. I haven't been for two years but my doctor's office has obliging refilled prescriptions for statin drugs (for cholesterol - even though I don't think it is necessary) and Prolia (bad bones). I'll have to roll up to his office one of these days as I need a referral for a bone density test and maybe a colonoscopy. I am going to have cataract surgery in May .. so I'll go for my "wellness test" in June .. or July .. maybe ...or August .. or ....
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Re: Medicare annual physical vs wellness visit

Post by Broken Man 1999 »

dodecahedron wrote: Mon Mar 18, 2019 1:11 pm
dm200 wrote: Mon Mar 18, 2019 12:38 pm
Edited to add: since most Medicare Advantage plans (Part C) integrate Parts A,B, and D, their subscribers may have a smoother time with their getting shots covered
.

Yes - our experience.
I think Medicare Advantage plans (Part C) have two very strong incentives to cover vaccines:

1) since they are on the hook to pay treatment costs if the member gets sick, they have an interest in preventing the disease

2) Medicare ¨rates¨ MA plans from one to five stars and highly rated plans like to promote their star ranking in their ads. One factor in the star ratings for Part C is the percentage of their members who are up to date on immunizations.

Interestingly, stand-alone Part D plans also have star ratings but the percentage of immunized subscribers is not a factor in Part D ratings, only in Part C ratings.
I will say this, if anything, my Humana Medicare Advantage PPO is very aggressive in trying to set up at-home evaluations of my health by a doctor, pharmacy reviews of my medications, many reminders for things like eye exams, flu/shingles/pneumonia/ whatever immunizations. I cordially decline most of their offers, as I am usually ahead of them, having completed their recommended activities earlier. My PCP has been my doctor for almost 20 years, same goes for many of my specialists. So I'm fine for the things I know my doctors recommend. I have always been a person who will follow doctors' health plans, seems foolish to go to the doctor, then ignore his/her health plan for me. I have the upmost respect and confidence in all my doctors. And, only one is as old as I am, my pulmonary doctor. He is in his late 70ties. He will probably outlive me.

I give Humana credit for their outreach activities, it might be just the approach needed for some seniors to get 'em in to address their health. But, for me it isn't necessary.

Broken Man 1999
“If I cannot drink Bourbon and smoke cigars in Heaven then I shall not go. " -Mark Twain
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Re: Medicare annual physical vs wellness visit

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I will say this, if anything, my Humana Medicare Advantage PPO is very aggressive in trying to set up at-home evaluations of my health by a doctor, pharmacy reviews of my medications, many reminders for things like eye exams, flu/shingles/pneumonia/ whatever immunizations. I cordially decline most of their offers, as I am usually ahead of them, having completed their recommended activities earlier. My PCP has been my doctor for almost 20 years, same goes for many of my specialists. So I'm fine for the things I know my doctors recommend. I have always been a person who will follow doctors' health plans, seems foolish to go to the doctor, then ignore his/her health plan for me. I have the upmost respect and confidence in all my doctors. And, only one is as old as I am, my pulmonary doctor. He is in his late 70ties. He will probably outlive me.

I give Humana credit for their outreach activities, it might be just the approach needed for some seniors to get 'em in to address their health. But, for me it isn't necessary.
A longtime friend of ours has been on a Humana MA plan for many years and is very happy. He also tells me that (no charge) Humana sends a nurse to his home and does tests/evaluations/recommendations.
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Re: Medicare annual physical vs wellness visit

Post by drawpoker »

Lynette wrote: Mon Mar 18, 2019 1:30 pm .....referral for a bone density test.....
If you are female when you first go on Medicare the bone density scan is one of the "free" screenings you get automatically (no referral needed)

Did you not get this during your first year......?
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Re: Medicare annual physical vs wellness visit

Post by dm200 »

drawpoker wrote: Mon Mar 18, 2019 3:24 pm
Lynette wrote: Mon Mar 18, 2019 1:30 pm .....referral for a bone density test.....
If you are female when you first go on Medicare the bone density scan is one of the "free" screenings you get automatically (no referral needed)
Did you not get this during your first year......?
Only for females?

I am male, but diagnosed with Osteoporosis. I have had several bone density tests while on my Medicare plan - and I think I only paid a small copay ($20 I think) - same as for X-Rays and Ultrasounds.
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Re: Medicare annual physical vs wellness visit

Post by munemaker »

dm200 wrote: Mon Mar 18, 2019 3:44 pm
I am male, but diagnosed with Osteoporosis. I have had several bone density tests while on my Medicare plan - and I think I only paid a small copay ($20 I think) - same as for X-Rays and Ultrasounds.
On my Medicare Advantage Plan:
- The premium is $40/month
- ECGs, X-rays & ultrasounds are $10.
- CT Scans and MRIs are $100.
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Re: Medicare annual physical vs wellness visit

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munemaker wrote: Mon Mar 18, 2019 4:01 pm
dm200 wrote: Mon Mar 18, 2019 3:44 pm I am male, but diagnosed with Osteoporosis. I have had several bone density tests while on my Medicare plan - and I think I only paid a small copay ($20 I think) - same as for X-Rays and Ultrasounds.
On my Medicare Advantage Plan:
- The premium is $40/month
- ECGs, X-rays & ultrasounds are $10.
- CT Scans and MRIs are $100.
My plan monthly premium is $36. X-rays, ultrasounds, etc. $20
CT and MRI scans $150
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