Costly Confusion: Patients Caught by Medicare Not Covering Annual Physical Exams

Yves here. This post presents a classic example of why medical care in America sucks. It’s too much about billing and not enough about patient care. I know patients who can have a yearly visit to an MD covered under their plan as either a physical or a medium complexity visit for conditions for which they are already being treated, and have to remind their doctor how to code the any tests so as to have the insurer accept the claim.

And it’s not efficient from a health care system perspective to have Medicare patients go for what is essentially a pro-forma visit (which sounds as if it could be handled by a nurse rather than an MD, and the article indicates that the subject would have seen a non-doctor for this visit) and then have to come back to deal with real issues, which anyone of Medicare age is likely to have? If nothing else, most people that age are taking some medications, and in every state I am aware of, scrips are valid for only a year, necessitating a doctor visit.

And FWIW, my Manhattan MD charges less for my annual physical than the case study in this article.

By Michelle Andrews. Originally published at Kaiser Health News

Shorter: patients should not be required to play games in order to escape paying costly medical bills.

When Beverly Dunn called her new primary care doctor’s office last November 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 spent a lot of time with her.

Until she got the bill: $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.

Dunn, of Austin, Texas, 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.

“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.”

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 visitis 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.

At their first wellness visit, patients will often fill out a risk-assessment questionnaire and review their family and personal medical history with their doctor, a 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.

They may also talk about advance care planningwith beneficiaries to make decisions about what type of medical treatmentthey want in the future if they can’t make decisions for themselves.

At subsequent annual wellness visits, the doctor and patient will review these issues and check basic measurements. Beneficiaries can also receive other covered preventive services such as flu shots at those visits without charge.

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.

Over the years, preventive services have gradually been added to the program, and the Affordable Care Act establishedcoverage of the annual wellness visit. Medicare beneficiaries pay nothing as long as their doctor accepts Medicare.

However, if a wellness visit veers beyond the bounds of the specific covered preventive services into diagnosis or treatment — whether at the urging of the doctor or the patient — Medicare beneficiaries will typically owe a copay or other charges. (This can be an issue when people in private plans get preventive care, too. And it can affect patients of all ages. 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.)

And to add more confusion, Medicare beneficiaries can opt for a “Welcome to Medicare” preventive visit within the first year of joining Medicare Part B, which covers physician services.

Meanwhile, some Medicare Advantage plans cover annual physicals for their members free of charge.

Many patients want their doctor to evaluate or treat chronic conditions like diabetes or arthritis at the wellness visit, said Dr. Michael Munger, who chairs the board of the American Academy of Family Physicians. But Medicare generally won’t cover lab work, such as cholesterol screening, unless it’s tied to a specific medical condition.

At Munger’s practice in Overland Park, Kan., staffers routinely ask patients who come in for a wellness visit to sign an “advance beneficiary notice of noncoverage” acknowledging that they understand Medicare may not pay for some of the services they receive.

As long as beneficiaries understand the coverage rules, it’s not generally a problem, Munger said.

“They don’t want to come back for a separate visit, so they just understand that there may be extra charges,” he said.

Beneficiaries may not be the only ones who are unclear about what an annual wellness visit involves, said Munger. Providers may be put off if they think that it’s just another task that adds to their paperwork.

A recent studypublished in the journal Health Affairs found that in 2015 just over half of practices with eligible Medicare patients didn’t offer the annual wellness visit. That year, 18.8 percent of eligible beneficiaries received an annual wellness visit, the analysis found.

Primary care physicians generally want to see their patients at least once a year, Munger said, but it needn’t be for a complete physical exam.

A wellness visit or even a visit for a sprained ankle could give doctors an opportunity to check in with patients and make sure they’re on track with preventive and other care, Munger said.

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.

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.

Dunn is considering her options. She would like to stay with her new doctor, who came highly recommended, and she’s worried she might have trouble finding another one just as good who accepts Medicare. But $300 seems steep to her for a checkup.

“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.”

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  1. ambrit

    I’m not eligible for Medicare yet, but the way my hypertension meds are handled shows another “trick” in the medical rent extraction playbook. To wit, the scrip may be good for a year, but the number of refills scheduled for that years time are nowhere near enough to carry someone like me, and I’m guessing many, many other people ‘up in age’ for a full year. So, one needs must ask the physician for a renewal of the prescription, in my case, every three months. This is usually tied to an office visit, which, this being a Medical Rent Extraction process, involves more fees. I have been able to argue the physician into reauthorizing the prescription over the telephone every other time, but I still get forced to pay for an office visit twice, and once, three times a year when one visit a year would have been sufficient.
    To cut my physician some slack, I did argue this exact point with her last year, whereof she ‘sort of’ “admitted” that the multiple yearly visits were “encouraged” of the doctors by the holding company that ran the physician’s and clinic’s network. So, literal rent extraction in action.
    The other indignity that we here in the ‘Deplorable Patients’ group are subjected to, this being a sort of community clinic, even though a subsidiary of the largest hospital group in the region, is the requirement that one and all pay up front, before seeing the doctor.

    1. Sanxi

      ambrit, you sound angry, fair enough. Have you discussed the ‘Medical Rent Extraction process’, with your doc? I’m not your doc, so I can’t say, (really I don’t know anything about your situation) but if you feel there are too many visits you need to speak up. You may not want to, you may not like to, and you may not feel you should have to but that’s the way things are right now. If you don’t feel up to it bring along someone who does feel like it. In general speaking up to a doc, who you’re sure is listening goes a long way. Insurance companies – best to use some of Yves methods or a lawyer.

      1. flora

        Ambrit writes he already argued the point with his doc, who ‘sort of’ “admitted” his point. However, said doc’s practice is owned by a holding company that sets the rules for the doc. The doc’s corporate boss is the problem.

      2. Evil Wizard Glick

        Offices ONLY profit from a visit.

        It is one of the biggest scams in medicine.

        The Wellness exam may be covered but if you discuss anything beyond that you get billed. Doctors know that they are literally nickel and diming Medicare/Medicaid to death.

        Google up the 2005 Seattle Times series Suddenly Sick. They suggest that BIGPHARMA is changing the numbers to make a profit. Thus dropping BP to 120/80 amazingly places a third of the populace in the “High Blood Pressure” need medication fear mongering category.

        Same is true with the inaccurate Ha1c Blood sugar test. The ONLY accurate test is daily Glucose monitoring, but as soon as they notice the elevated A1c it starts medication recommendations.

        Things like Sickle cell anemia and longer or shorter-lived red blood cells make the test inaccurate. A study listing nearly twenty odd markers which will cause inaccuracy.

        I’m not even going to get into just how dangerous trusting your doctor can be.

        I also suggest a daily read of Retraction watch.

        The third-leading cause of death in US most doctors don’t want you to know about

        A recent Johns Hopkins study claims more than 250,000 people in the U.S. die every year from medical errors. Other reports claim the numbers to be as high as 440,000.
        Medical errors are the third-leading cause of death after heart disease and cancer.

        1. Oh

          Methinks that Physicians rely too much on analytics (numbers from tests) rather than look and feel of the patients. I’m surprised that they still use the stethoscope! Soon they’ll be using their iphone for diagnosis.

          1. Evil Wizard Glick

            No. It is because they became a business.
            The more patients they can see in an hour the more profit they make.
            On top of that if you question your doctor you can get banned from that office for life. And have a adversarial patient description added to your medical records. Making it less likely for other doctors to see you.
            This is a major problem in small communities.
            Even though one has the right to view their medical files and add letters detailing when one disagrees or uncovers mistakes in the records very few patients actively use that aspect.
            One should review all medical records and doctors notes ate least every six months.
            I am a five foot six grey haired man who had medical records describe me as a six foot Blonde.

            1. TBone

              We have also encountered this phenom since our local semi-rural hospital was gobbled up by a giant neighboring corprate-run behemoth. Ugh.

        2. Yves Smith Post author

          Another US disgrace.

          In Oz, doctors will consult with established patients on the phone. There is a charge, lower than for an office visit. They also charge for renewing or issuing a scrip with no office visit. The charge for me (a non-insured patient in their system) was $15 in 2002 v. $75 for an first time office visit with a GP (specialists were more….).

  2. ggongi

    I manage a small private medical practice and code all of the claims for it.

    Yes, it’s true: Medicare Part B pays for only two types of outpatient office visits: ‘sick’ visits (whether due to acute or chronic conditions), and Annual Wellness Visits (AWV), which consist of a Health Risk Assessment (HRA) interview, the formulation of a Personal Prevention Plan based on the results of the HRA interview, and optional Advance Care planning. It does not pay for ‘adult annual physicals’, which every ACA-compliant plan is required to cover, and which most commercial plans also pay for.

    As for Ms. Dunn in the post receiving a bill for $400 for her annual checkup: that is sheer obtuseness IMO on the part of that practice. Medicare pays generously for the AWV HRA visit: typically $165 for a Medicare beneficiary getting it for the first time, and $125 each subsequent time. The Advance Care planning counseling pays an additional $80 or so, which is even more than what Medicare pays for a typical sick office visit, $75. I suspect that’s because they want as many beneficiaries as possible to sign DNR orders; inpatient end-of-life heroic interventions are where the majority of Medicare expenditures happen.

    Medicare will also pay, for the same date of service, for any hands-on physical examination and diagnosing that happens during the AWV; you only have to bill it separately as a sick visit.

    What if there’s nothing wrong with the Medicare beneficiary? My response to that is I have yet to encounter anyone who qualifies for Medicare who at some point has not experienced at least fatigue; or aches or pains at least every now and then; or had symptoms of a respiratory infection in the past year; or whose BMI fell outside of the ideal range. Many combinations of the above would suffice to get Medicare to cover the diagnostics that would be required in a typical adult annual physical: a comprehensive metabolic panel, blood count, and thyroid function labs. As for a lipid panel: Medicare will pay for that on a screening basis every 12 months, even for someone who does not have hypercholesterolemia, hypertension or heart disease. And diabetes screening with the gold standard hemoglobin A1c lab: Medicare will pay for that for anyone who has any abnormality at all in any other lab, or anyone who has been on any long-term prescription therapy. EKGs: Medicare will pay for that on a screening basis if it’s done on the Welcome to Medicare visit. Any other time? They’ll pay for it if the beneficiary has ever had an episode of chest pain, has hypertension, or any heart condition.

    So I have a hard time understanding why Ms. Dunn’s doctor’s office had to insist on billing Medicare the adult annual physical preventative CPT code, when Medicare would have compensated them just fine if they did an HRA interview, and in addition billed a sick office visit for any hands on examination, diagnosing, evaluating and management of the patient.

    Btw I’ve been a reader and fan of yours since the days when Tyler of ZH used to guest post; I happened upon NC in a past life in finance, during the lead-up to the GFC. You’re a bastion of clear, humane thinking in a world gone mad with neoliberal idiocy and corruption. I don’t know which industry has it worse: finance or ‘healthcare’.

    1. Louis Fyne

      thank you for taking the time to share your knowledge.

      i love comments like these that provide insights that would never see the light of day in our glorious newspapers of record, morning news shows or even NPR.

      my fam/seniors who I know thank you in advance.

    2. ChiGal in Carolina

      Amidst all the gnashing of teeth, this is a remarkably constructive and informed comment that will do real good for many.

      I have bookmarked it. Thank you, thank you, thank you!

    3. ggongi

      I’m happy to be able to help people navigate the Byzantine billing aspects of our current health system, such as it is.

      One thing to keep in mind is that Medicare Part B has an annual deductible of $180 or so, and then a coinsurance of 20% after the deductible is met. So if a beneficiary hasn’t met his/her deductible, a sick visit that’s billed alongside an AWV will go towards the deductible which the beneficiary will have to pay out-of-pocket, unless he/she has a Plan F Supplement. But the deductible amount that a provider is allowed to bill the beneficiary is limited by their Medicare contract: for a level 3 established patient visit it’s around $72; a level 4 established patient visit is around $105. Unless the beneficiary has multiple, serious, uncontrolled chronic conditions, which require immediate intervention, a provider should not be billing a level 5 visit for the sick visit portion.

      As for Medicare Advantage (MA) plans: all of the nationally-available ones that I’m aware of (Aetna, BCBS, Cigna Healthspring, Humana, United Healthcare, Wellcare) pay for the adult annual physical preventative CPT code. But keep in mind that all of these MA plans are private insurance masquerading as Medicare. If a beneficiary opts to sign up for one of these instead of traditional Medicare, they forego some of the billing protections that traditional Medicare offers beneficiaries. MA has to be one of the biggest rackets in the economy, but that is the topic of another discussion.

      Unfortunately as the OP makes clear, our current system requires that both patients and providers need to be something approaching coding and billing experts. But ICD coding and Medicare “medical necessity” requirements are not something that is taught in medical schools; in fact the profession resists such training as if it is somehow beneath it. I think medical schools should require a semester of such training, as long as we have our current system of payment for health care services. A lot of bills that patients get are the result of either inadvertent or deliberate ICD or CPT coding errors when a provider orders lab, imaging or other tests; or submits their claim for an office visit.

      The good news, if it can be called that, is that Medicare publishes exactly what it covers, and under what conditions. A beneficiary can use this information to dispute bills, or to get their provider to resubmit incorrectly coded lab/imaging orders, or claims for office visits.

      Preventive services that Medicare covers

      How providers should code for Welcome to Medicare and AWVs

      Medicare’s national medical necessity rules for a wide variety of procedures

      Medicare Administrative Contractors’ (MAC) regional medical necessity rules (requires that the beneficiary know who their MAC is)

      Medicare’s national medical necessity rules for many commonly ordered lab tests; updated quarterly

      The differences between the various Medicare Supplemental Plans

      Preventive services that all Obamacare plans are required to cover with no patient cost-sharing

      1. flora

        Thanks for this. I’ve printed out your 2 comments and will bookmark the links you list above. You’ve given NC readers some very useful information.

      2. RubyDog

        Thanks for taking the time to post this information and these details. I’m a recently retired Family Physician, and believe me, trying to keep up with the nuances and rules and annual changes around coding was more onerous than learning medicine in the first place, not to mention the time taken away from direct patient care.

      3. Janie

        Bookmarked! Thank you so much for contributing this, and thanks to Yves for initiating the discussion and providing the forum.

        I’ve worked with ICD codes; yes, one does have to be aware of what codes to use to tie the diagnosis code to the procedure being billed. The administrative costs of recoding and rebilling denied claims is huge, especially for services provided outside the MD’ s office. The outside provider translates verbiage from the medical office into codes, and we spent a lot of time checking back with the doctor’s office to verify the diagnosis. We wrote off smaller balances, especially for Medicaid patients, as being too costly to pursue. It was an inordinately wasteful process that has gotten worse. My CPA spouse used to say that, if the manual system was disfunctional, all computers did was to speed up the revolving mess.

      4. run75441

        This: “MA plans are private insurance masquerading as Medicare. If a beneficiary opts to sign up for one of these instead of traditional Medicare, they forego some of the billing protections that traditional Medicare offers beneficiaries. MA has to be one of the biggest rackets in the economy, but that is the topic of another discussion.”

        I wish you would explain some of this for many of the readers here in terms of additional funding for Advantage plans. As you pointed out, people lose some of the protections they have under original Medicare.

        1. Jack Gavin

          I also would like more information on the MA/Medicare distinction. We just went through the decision process – pick an MA or stay with Medicare. We stayed with Medicare more through luck and some second hand word of mouth advice. Not the best way to make decisions. I fear the next time our retirement plan will not offer us a choice but will impose a Medical Advantage plan on us. We’d like to be ready. Thanks again for your wonderful info.

          1. run75441


            I added some comments below ggongi’s comments about both. He or she did cover the distinction well which is why I asked he or she cover it. Before you go flip flopping back and forth, you need to ask questions about underwriting and whether you will pay a premium price for doing such due to pre-existing conditions. Get the answers before you do it.

        2. ggongi

          The biggest financial protection that a beneficiary gives up by signing up for a MA plan is “limitation of liability.” Under traditional Medicare, a participating provider is not allowed to transfer liability to a beneficiary for a claim that’s been denied either for: i) being medically not necessary (see links on Medicare’s rules for medical necessity in prior post); or ii) being too frequent; unless the provider has given the beneficiary an Advance Beneficiary Notice of Noncoverage (ABN) to sign, by which the beneficiary gives their consent that they’ll pay for a service that Medicare won’t pay for in this instance by virtue of reasons of type i) or ii).

          ABNs do not apply to MA plans. See here:

          Now MA plans are supposed to follow Medicare’s medical necessity rules, but if a MA plan denies a claim for whatever reason, just like with private insurance, the provider is allowed to transfer liability to the member, and at the full charge that the provider submits on the claim, without any contractual discounts or adjustments. Under traditional Medicare, besides the ABN-signed charges, the only things a participating provider is allowed to charge a beneficiary are the deductible and coinsurance.

          Second: narrow networks and geographical limitations to where you can use your MA insurance. The vast majority of doctors overall in the US, particularly PCPs, participate in traditional Medicare:

          But say someone with traditional Medicare unwittingly sees a non-participating doctor. That doctor is still supposed to submit a claim to Medicare, and they are limited by law as to how much more they can charge a Medicare beneficiary than what Medicare pays them: 15% more, that’s all:

          What’s more, a beneficiary can use traditional Medicare at any doctor in the country that accepts Medicare. If the beneficiary generates a lot of claims far from their home address, Medicare might ask for an explanation, but that’s it.

          With MA plans, just like with private insurance, if the provider is not contracted with a particular MA plan and a member sees them, once the provider’s claim is denied, the member is on the hook for the full submitted amount on the claim.

          I have seen this first-hand repeatedly with MA members who are patients at our practice going to emergency room, being released, and then being referred to outpatient specialists that are not contracted with their MA plan. If the specialist group had any scruples they’d inform the member that they don’t take Humana Medicare, or Cigna Healthspring, or whatever, but they often do not. I’ve intervened in some cases, asking the specialists as a professional courtesy to limit their charges to what they would have been paid by traditional Medicare, and not the 10 times or 20 times that amount they submitted on their claim. Sometimes my plea works, sometimes it doesn’t.

          Just like with Obamacare, some MA plans, particularly the HMOs, are limited to a particular sub-region of a state. Something to keep in mind.

          Third: “Prior Authorizations” (PA) or referral requirements. Every MA plan has them; some have more of them, some have fewer. I have seen this repeatedly too: unscrupulous facilities will go ahead and perform diagnostic imaging that needed a PA from the patient’s MA plan without getting the PA. And then the member is on the hook for the full denied amount on the claim.

          Traditional Medicare has no PA or referral requirements, except for certain types of durable medical equipment (DME).

          Fourth, incentives: the only way for these MA plans to make money is to take more from CMS for their members than what they pay out in benefits for them. These MA plans are essentially arbitraging CMS on the one hand, and providers and members on the other. They have every incentive to transfer responsibility to their members whenever they can get away with it.

          With doctors, they squeeze as much out of them as they can, transferring as much administrative work onto them as possible; and getting them to jump through “Quality Measures” (QM) hoops and trying to get doctors to find and code as much “risk” as possible in their members. The QMs and risk adjustment factors (RAF) are the two ways they increase their capitation payments from CMS for the members they have enrolled. They want as high a RAF as possible, but as low a utilization of benefits as possible.

          All of this is not intended as advice not to sign up for a MA plan. MA plans include Rx drug coverage, and sometimes vision and dental, and even gym memberships, where traditional Medicare includes none of those things. Also with traditional Part A, a beneficiary’s out of pocket expenses for long enough, and repeated enough, inpatient episodes is theoretically unlimited. MA plans have a yearly out of pocket max. It may be high enough that bankruptcy might also ensue, but they have a max.

          MA was sold as a way to cut down on Medicare costs, while maintaining and improving quality of care for Medicare beneficiaries. I’ve looked, but I can’t find any published figures as to how much money these MA plans have saved CMS. I suspect it’s little to none; whatever ‘savings’ there are have flowed to the insurance companies’ bottom lines. What I have found is that, every year, more and more players are clamoring to get into that market. In particular the “Special Needs Plans” (SNP) market — the ones where the seniors have Medicaid as secondary insurance. Apparently the capitation payment from CMS for those beneficiaries is the highest. But what the MA plans pay out on SNP claims is the lowest — Medicaid’s fee schedule, not Medicare’s. Which is 70 – 80% of Medicare’s fee schedule. No wonder why so many of them want in on that space.

          1. run75441

            Thanks ggongi!

            To add to ggongi comments.

            Medicare Advantage is also funded by Medicare and a percentage is paid to the MA plans to cover its enrollees. Movement to a better plan is also not advised as they can drop you from the plan if you become ill or sick after moving. MA plans are also tasked with reducing costs and they get bonuses for doing so. In the end MA plans cost more. As ggohgi says there is a balance between service and payment which is not foun in Medicare original.

            To cover much of the out of pocket expenses in Part A&B of original Medicare, go with a Medigap Plan. There are levels to this also. Plan N is one and the best is Plan F and also G. You will pay more for the later two plans. Upgrading plans may also cause you to be evaluated through underwriting. With N and G, you will pay the Part B Deductible. With Plan F you will not. In 2020, they will do away with Plan F and every Medigap plan for Medicare original will involve paying the Part B deductible.

            Another factor has popped up in hospitals and especially Emergency Departments/Rooms . . . third party contractors. There is not guarantee your doctor at the ER works for the hospital. If they are 3rd part and contracted to the hospital, you could be billed by the company the doctor works for in addition to what your are billed by the hospital. This will not happen with Medicare Original to my knowledge. Just remember that as you are squirming in pain from a gall bladder attack, appendicitis, or a heart attack and have a MA plan.

            Medicare – original does not cover dental or vision; however, it is still good medical coverage. For dental, plan on $1500 per year for a great plan (Delta) for a couple. Vision I have not price; but, you can always go to Costco or Sams for glasses and contacts for far less than a plan. Many dental schools will take patients so students will learn.

            Always ask tons of questions.

            My $.02

    4. Evil Wizard Glick

      I have known about the Wellness problem for a couple of years now. If I recall the visits cost taxpayers about $500 each. That’s taxpayers.
      Many seniors wait for the free Wellness visit not realizing ANYTHING outside the defined visit gets billed.
      This is a minor scam doctors use to profit from the visits which would otherwise cost their office by eating up paying patient time.
      In the long run this excess billing will eat up an already burdened system. Thus eventually forcing costs even higher and removing minor accepted practices due to affordability.
      On top of that many doctors over prescribe medications. Many nursing homes use this as a way to control patients. If your BP meds make you dizzy you are more likely to remain seated or in bed all day.
      Most doctors are unaware of the Beers list detailing side effects on seniors.
      Most doctors have no idea how common meds effect the mentally ill.
      Below are a couple of articles relating to the billing issue.

      From 2014

      Your free annual checkup might not be free. During the first 12 months you have Medicare Part B, you can get a free “Welcome to Medicare” preventive care doctor’s visit, and after that retirees are eligible for a free annual wellness checkup. However, depending on what tests or services your doctor orders during this visit, you may still end up with a bill. While Medicare covers a variety of preventive care services with no cost-sharing requirements, if your doctor recommends a test or procedure that isn’t considered preventive or you get a test more often than Medicare covers it, you may have to pay coinsurance and the Part B deductible may apply. “If the doctor orders a test and it falls under Part B, you could very well have to pay 20 percent of those test costs,” says Allison Hoffman, an assistant professor of law at the UCLA School of Law. However, supplemental plans such as Medigap and Medicare Advantage plans may fill in some of these cost-sharing requirements.

      From 2016

      For consumers, this is perhaps one of the more confusing aspects of Obamacare, which does indeed cover certain free preventive services and so-called wellness visits but stops short of free annual physicals.

      Complicating things, patients might go in for free preventive care covered by the law, mention some unrelated ailment and find out later they were billed for a normal office visit.

    5. Yves Smith Post author

      This is super helpful! But this leads to the question why Kaiser Health News, which is supposed to be an expert on this topic, didn’t call out the MD as you did.

  3. Sanxi

    As an MD (PhD MD, a few other things), I must ask what is the point of this post, is in – that patients are trying to gaming the system to avoid paying the bill? And doctors (presumably acting accordingly to some set of non grifter ethics) are what outraged by this? And they feel put upon to act like cops? Or wish they were cops? Feds out to get’em?

    To be clear: any way to help patients legally game the system is a good thing. I took an oath to protect life not rob people or even to get rich. Health. Care. System. To actually call it a “system” implies it functions in some rational manner, where it doesn’t. Re: the post. Who are these people? Med Inc., It’s become all about greed and the money. I find the article offensive, the subject itself offensive, and the docs referred to it offensive and they should be sued so as to be encouraged to take up another line of work.

    On a positive note there’s a lot a good doc can do, especially if they are not in a mega practice (cause they got rules) to smartly use the flexibility in practicing ‘watchful medicine’. In that way, (some might think this overly cautious) (that would be insurance companies, too bad) a doc can go a long way to shift costs from the patient to whomever. Better to nip things in the bud as in were, so that nothing gets out of hand. Early detection and early treatment, continuous treatment if need be, (but not continuous billing to you) with a full range of treatments. Coding things right is just the start of seeing things right. Alas, no one wants to hear docs blame patients about, well anything. So don’t.

    1. Yves Smith Post author

      Ahem, do you have a reading comprehension problem? I suggest you reread the introduction. I have no sympathy for defenses of the crappy US medical system, which is what your remark amounts to.

      The point of the post is that Americans should not live under a system where patients have to worry about coding to have services covered. If the US were like any other advanced economy, patients would not be facing a bill at all, or only trivial and highly predictable ones not subject to vagaries of how they booked a visit.

      1. Sanxi

        What I should have said but didn’t was my issue was not the post, it’s selection, or the wisdom of its being posted. I thought the content of article itself was awful, what it was saying was bad and the choices it presented as were not good. I was trying to agree with the idea that this is messed up,something not right, has to be fixed, gotten rid of. It’s actually much worse, there a whole legal component to it, a whole avoid fraud thing. Look I’m not clever or trying to be smart guy, just had a different voice in my head that what I maybe wrote and maybe you heard. Do better next time.

        1. flora

          an aside: I’ve been reading your various comments with some amusement. I *think* you’ve commented, over several posts, that you grew up and were educated in US, moved to EU, currently work and teach in EU. It’s hard to tell if this is accurate since comments have been a bit all over the map. Yet, you here comment on the US med/medicare system, which you’re clearly unfamiliar with, judging from your comments in this post. My 2 cents.

        2. Pat

          Yes in a sensible world fraud would apply. But in the topsy Turvey world that has been created in America where corruption, fraud and even worse are the norm, the only fraud would be the doctor who actually gave a physical finding a way to bill it so that the patient got the health care they should. Instead we have a free wellness check which could mostly be done over the phone except for the weight and blood pressure, but gets up charged to the patient if anything beyond a yeah you still exist is needed or just done.

          As it is clear you aren’t practicing in the America the rest of us live in Please understand something, Doctors on the ground are rarely in charge anymore. They are cogs in the for profit medical system monster we have in this country. One that has been enabled and legalized by our also corrupt political system. They have designed the process to make the public pay twice or more between the insurance, even in Medicare anymore, and the items needed that aren’t covered but should be. At least with Medicare, you don’t get hit with the charge for the out of network anesthesiologist, one of my favorites.

        3. EoH

          Is the second to last sentence undo humility, because most people would regard someone with an MD, a PhD (a few other things) as both clever and a smart guy.

          Your posts seem alternately defensive of the medical establishment, uninformed, and apologetic. As your dissertation adviser might have said, sometimes, all it takes is rewriting to turn mishmash into something intelligible and interesting. Not that everyone will agree with it, mind.

          The US medical community is a world like any other: it has its Schweitzers, its Hawkeyes and Trapper Johns, and people who would have fit in better at Goldman Sachs. Institutionally and historically, it has been an enormously successful trade association that has not been much in favor of change. Radical change is what we now need most.

  4. Sanxi

    All, any single Doc can do now is what? Give up? You assume to much. I am not the enemy. The article points to docs doing something that is a much bigger problem that you may be unaware of which, is prosecution for fraud. All bills are submitted under the statement that errors are assumed to be first frauds. The US Attorney will show up. Over $50. Seen it. They will make your life impossible. Rent seeking is way down on the list of to dos. Which I’ve never seen. Heard of though. Who benefits from pitting Docs v. Patients whoever is making the billions in healthcare which isn’t me or you. I do what I can with I got including voting and supporting people like AOC, and making a pest of myself in my local med community. More than a pest actually. Actually, I’m dyslexic which I’ve mentioned before, but I don’t think I missed anything. Different emphasis maybe, not a bad one though, I’m fighting battles that’s the scale I can work on and I’d wish we’d win the war too on that I need help, we all do.

    1. Joe Well

      The entire medical profession is, structurally, rent-seeking. A “low” salary for a doctor in the US is $189,000, with typical medical debt of a med school graduate of about $150,000. The median income for an individual in the US is $31,000. This has been achieved by the AMA limiting the number of doctors (through limiting new med schools and the de facto wall against immigrant doctors in the form of absurd education requirements) and lobbying against universal healthcare.

      If you are in favor of burning this system down and building a new one, and lowering your income in the process, I thank you.

      The article is directed at the system itself, not the choices of individual MDs. As with almost everything in society, most of the problem is at the system level and individuals can do very little.

    2. Janie

      Sanxi is right that jiggering the diagnosis to get paid for work legitimately ordered can be prosecuted for fraud. Yet, what to do? The science precedes rewriting the codes by several years. The prescribing doctor can submit an appeal, documenting research backing the performed procedure – in his or her spare time (sarc).

    3. Yves Smith Post author

      A doctor above said the way the visit was coded was wrongheaded and there was no reason the patient should have been subjected to it.

      And US attorneys only show up for large scale Medicare fraud. Help me. It’s not “jiggering the diagnosis”. The diagnosis simply has to conform with the patient’s condition and codes are so complex that there are often multiple codes that apply even to generally healthy people.

      Did you miss that hospital employees take courses on how to “upcode” and no one regards this as fraud? As in no one is prosecuting the organizations that give these courses or the hospitals that enroll employees?

  5. TBone

    “Patients are trying to gaming the system to avoid paying the bill? And doctors (presumably acting accordingly to some set of non grifter ethics) are what outraged by this?” is an offensive statement to people who are paying for Medicare and paying premiums for “Advantage” plans and receiving invoices they can’t make heads or tails of! The “rent extractors” are, as we all know, the corporations/billing organizations who are inserted in between the doctor and patient, siphoning off huge administrative fees and requiring unnecessarily complicated schemes for payment of what should be simple invoices stated in plain English!

  6. Bob


    Here’s an approach for meds that has worked on a personal level –

    Ask that the doctor issue the prescription for maintenance meds (e,g, blood pressure meds) on a 90 day basis.

    And then ask that the meds be issued as a double dose which the patient (you) can break in half.

    This means that you receive a 180 day prescription and avoid the hassle of dealing with Big Pharma on a shorter term basis.

  7. doug

    I guess my doctor ‘cheats’. I have annual wellness exam that includes bloodwork and I see the doctor. I will add that the doctor and staff try hard to ensure my costs are covered. I consider myself very fortunate when I read about such as the example.
    It should not be random, or luck of the draw …
    We need better badly…

  8. TBone

    Prosecution for fraud is NOT the much bigger problem. The entire “system” being set up the way it currently “operates” (fraudulently) IS the problem! Profit should not be a factor anywhere in the equation.

  9. brook trout

    At my recent wellness visit to the large university medical group (having left my previous physician when she committed medical fraud, billing a Level 3 visit as a Level 5, the various “levels” of visits themselves another burr under my saddle), I was handed a paper that explicitly warned about upcharging the visit to a physical if the visit strayed outside its proper bounds. I was pretty careful, but sure enough, I got billed for the extra. I was tuned down in the first appeal–pretty pro forma response from a low level employee–but got kicked up to a supervisor because of my, shall we say, rather vociferous disagreement. During the conversation with her, fortunately I knew enough to ask what the billing codes were that kicked this from a wellness visit to an actual appointment that I am to pay for, since somebody at one point had to code something in that determined this was more than a wellness visit. What I found was just a list of my few chronic, low-level conditions (occasional GERD, e.g.) that could have been lifted right off my (electronic, of course) medical record. I eventually got the chargers reversed, but the entire experience was another confirmation to me of the extractive nature of the system both providers and patients are caught in.

  10. jefemt

    I attended a ‘prepare for 2019’ Medicare meeting last autumn, hosted by an aspirational Congressional candidate. I assumed it was to be a discussion about the broader issue of the health CARE crisis in America. It actually really was a nuts and bolts discussion of the 2019 changes, strategies, etc.
    Of course, lots of war stories from the ‘victims’ of a ridiculously byzantine overly-complex system.

    Really disheartening stories— folks with very serious conditions facing unnecessary additional psychological stress due to the very real, personal fear and threat to their health and life- NOT receiving the care they need, and having to put unnecessary efforyt into simply getting to the doc and getting the CARE they need.

    My takeaway? Where is the outrage, and why in the world to we tolerate and put up with this sh*t?

    1. Carla

      I’ve been outraged since the (non-) system killed my husband in 1997. Things have only gotten worse. Please, everyone, if you possibly can afford it, pay $50 a year to join Physicians for a National Health Program as a “health reform advocate” if you are not a physician (there are different levels of membership for physicians). PNHP are truly the honest brokers in this fight. You cannot go wrong supporting them.

  11. drb48

    Just ran into this issue last year. My doctor refused to renew my one prescription without an office visit. Compelled to come in I scheduled a visit. Eventually got a notice from Medicare refusing to pay for the visit. Properly, as the office had billed it as my “Welcome to Medicare” visit instead of an “annual wellness” visit. As I’m 70 and have been on Medicare for 5 years, my “Welcome to Medicare” visit already happened 5 years ago. BTW the visit was with my PA as I never see a doctor for primary care. I contacted the office and pointed out the mistake and requested that they rectify it. Never saw any update from Medicare but never saw a bill either. So I’m hoping they straightened it out. I’ve also run into the form where you agree to pay for lab work in case Medicare doesn’t cover it. I refused to sign it as I’d already gotten burned by that once before. Also due to lab using wrong billing code. I said if they can’t confirm that Medicare will pay, then I’m not having it done. They waived it off.

    1. drb48

      p.s. – Doctors routinely request you sign a form waiving your right to sue them if they make a mistake and agree to binding arbitration instead. I refuse to sign that as well. Never had them refuse to see me as a result.

      1. J C Bennett

        I have taken to crossing out any language that I find, in any form that I am given to sign, in any medical office that I might frequent, that I do not agree with.

        I have never experienced any repercussion, whatever.

        1. ChiGal in Carolina

          Me three; I sometimes even write in the words NOT RESPONSIBLE FOR BALANCE BILLING OR OON CHARGES

          Never been prevented from proceeding.

  12. John

    What is really outrageous about the described predatory rent seeking medical access system is that the US already has much of the system everybody wants in the Veterans Admin healthcare system. You show up, present a card and receive care. Where it falls down is availability of hospitals which are relatively few and far between. So travel can be an issue. Combining the best of the VA and Medicare for all would be the best solution for everybody. The predatory rent extractors will fight this to the death.

    1. Allegorio

      I believe a National Health Service, as a division of the NIH, should be set up as well as Medicare for all, modeled on the British NHS. The system can test medical protocols for efficiency, provide clinics and hospitals in rural areas not provided by the commercial medical establishment. Think how the medical establishment would cover a pandemic. Public health would be the big selling point of such a system.

  13. RubyDog

    Just remember this is Medicare we’re talking about. Keep this in mind as we’re promoting “Medicare for all”. The existing Medicare system is also in need of significant reforms, otherwise the expected cost savings and efficiencies may not materialize. This is not to defend private insurers, but if you just look at the costs of the current US Medicare system and compare to the same demographic in other countries, we are still significantly higher. So we can’t just take the current system and simply extend it to everyone. We need a better system.

  14. Gene Kalin

    As a nearly retired internist of over 40 years (and a Medicare patient) please let me comment on the Wellness visits and the 3 months Rx.

    First off, for the properly set up primary care practice, the Wellness is a simple and easy income boost for the doc, and should present no cash burden on the patient. The way we do it, is to never make a Wellness appointment on its own. We do the Wellness concurrently and optionally only during a necessary medical office visit. Usually during a follow up visit, which for most Medicare patients with hypertension should be done every 3 – 6 months. Thus the 3 month Rx. Although in my practice I always give 3 Rx renewals, since I know my patients will return as recommended. I should also mention that very few patients option out of the Wellness part of the exam.

    I rarely do a visit for an ‘annual physical’ with Medicare patients. Because between the Wellness and the typical 3 – 6 months follow up visits, we make a point to cover everything. Most Medicare patients accumulate enough diagnoses and meds so that ‘routine’ testing is rarely done. Medicare does not like ‘routine’. So sure, sometimes I stretch things a bit in my patient’s favor. But nothing fraudulent! After all I am the patient’s advocate, not Medicare’s.

    1. ambrit

      Point taken. The legitimate “Medical Professional” is caught between the ‘rock’ of a heartless rent extraction system and the ‘hard place’ of his or her Professional Conscience. My Physician when I had a company sponsored health plan quit soon after I left that company. I saw him later and inquired about it. He remarked that he had begun to see symptoms of stress related heart trouble in himself and decided to quit as soon as possible, before the snowballing work demands of the profession ‘did him in.’
      My present Physician has several times tried to get me in to the Hospital for tests, since I ‘present’ with ‘out of normal parameter’ measures, such as blood pressure swings during an average day. I have so far refused on grounds of poverty and the marginal ultimate results predicted by my inability to pay for the anticipated procedures.
      She has been fairly frank with me about where a lot of the ‘pressure to conform’ comes from.

  15. mauisurfer

    I am a kaiser member old enough to have medicare, and I pay for “advantage”.
    I pay $25 for annual physical exam with my doctor, and I always get my doctor to approve
    annual blood tests the week before my physical so that we can discuss the results. The extensive blood tests cost me $5, and Kaiser says they are worth $621. They allow me to track my blood sugar, my cholesterol, and many other factors.
    My two adult “children” are successful professionals with expensive health plans, which do NOT cover annual blood tests. When I suggest annual blood tests, they say they cannot afford them.
    This is absurd – preventive care is the cheapest most efficient care.

    1. barrisj

      We are exactly in your situation: Medicare + Kaiser Advantage. Our annual “wellness check” includes a bloodpanel (no charge), vitals measurements, discussion first with RN, then primary doctor finishes up, usually with liver/abdomen palpation, check of lymph glands, stethoscopic exam of heart/lungs, and discussion of lab results and review of current medications. All for no charge. Granted our health situation is reasonably good, and a more intensive “physical exam” at this point is really not necessary, neither my wife nor I feel that there is any shortcoming in the “wellness check”…perhaps other plans are more restrictive as to physician hands-on, but we are pleased with the treatment accorded.

      1. mauisurfer

        I am satisfied with Kaiser advantage. After I go down there for my blood tests, I drive home, and some of the results are already on my computer, and the other test results dribble in over the next few days.
        My experience with Kaiser is that you have to find a doctor you respect, and build a relationship. Kaiser is a big bureaucracy, and it can be frustrating to deal with some of the people who work there. But your doctor can unlock the bureaucracy for you if you have a good relationship.

        1. barrisj

          Had Kaiser-Permanente in CA as part of employer plan, continued it in HI after retirement, and now covered in WA after Kaiser bought out Group Health…now enjoy complete coverage throughout West Coast and the Islands…what’s not to like?

          1. mauisurfer

            my problems with Kaiser:
            1. horrible phone system that forces patients to spend xxxx more time than would be necessary if kaiser were to hire x persons to answer the phone,
            frequently trapped in loops of recordings with repeated stupid messages telling me they are going to be closed on some holiday next month.
            2. a bureaucracy that favors itself over concerns for patient care.
            Recently they fired my favorite specialist because she did not want to continue to travel hundreds of miles twice a week, meanwhile she had more local patients than it was possible to see. Now she is in very successful private practice, and I am starting over with a new kaiser specialist who is about 10% as effective/intelligent.

  16. Steven Greenberg

    My Medicare Advantage plan has always covered by my annual physical. As I understand it, Medicare requires Medicare Advantage providers to give me an annual checkup.

    Maybe this is another good reason why I opted for Medicare Advantage rather than regular Medicare. The Advantage plan has an unfair government subsidy, but if Medicare continues to offer it, I am taking them up on it. I have no say in whether or not Medicare offers it, so I don’t consider myself as contributing to the general state of inequality in this country, at least on this one issue.

  17. dejavuagain

    Medicare Advantage is okay if you have access to high quality doctors in you area – in Manhattan, it does not seem like a great idea. Supplement plans will not cover the excess fee for an annual physical because these plans only cover the 20% which Medicare B does not cover. If Medicare B does not pay the 80%, then you or SOL for even the 20%.

    I just skip the annual wellness. Once you have an high A1C like I bet 50% of those over 65, then a lot of exams and test and drugs are covered.

  18. Joel

    What a scary thread. Im 63 currently have market rate unsubsidized Obamacare which basically means I pay around 500 a month for asset protection and have no healthcare whatsoever. I havent been to a doc in years try to eat right and work out like a fiend. But stuff is catching up. I thought in 2 years I would have some health care and could hold out but it sounds like that isnt the case. I guess the only solutions are either death or leaving the country.

  19. audrey jr

    I am front office for a local outpatient surgery center. We have a few patients who regularly cross out that with which they do not agree and will not comply on our “patient financial agreement” page and our “admissions agreement” page.
    I always wryly smile and wink when I see them crossing out passages.
    I like an informed patient.
    Health care in this country is most certainly a :racket.”
    I had a blood pressure/heart rate scare of my own while at work the other day and had to go to the nearest E.R. by ambulance. Probably a reaction to an antibiotic I was taking for a respiratory infection.
    Can’t wait for those bills to start coming in.
    Like Joel I am a only a few years away from Medicare coverage and I am terrified of having to seek medical care due to the financial stress of the experience.
    Keep yourselves in the best physical condition you can. Get as much cardio, core and upper body strength workouts as possible.
    If I knew of a country for older women I would certainly be planning to move there.
    But nobody wants old people.

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