Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
I got a statement today from Medicare that they denied coverage for an annual visit to my gyn doc. Showed it was billed as an annual visit age 50-64. I was 64 at the time of the visit (July 10th) but my Medicare started on July 1st and my birthday was July 13th. We have Medigap F through UHC (AARP), but I have been told that they won't cover anything denied by Medicare. Medicare did cover the tests done at the same time, but not the office visit.
Could this be a case of an incorrect code? I can't believe they denied something the very first time I used it. I had to deal with Aetna all the time for denied stuff and I DO NOT want the same hassle with Medicare!!
Medicare's coverage of routine or prophylactic care visits is spotty. Medicare technically doesn't cover physicals but it covers a wellness visit. However, the provider can't touch you. You'll have to see if it was denied due to the age or due to type of visit. Plenty of people below age 65 have Medicare.
Medicare technically doesn't cover physicals but it covers a wellness visit. However, the provider can't touch you. You'll have to see if it was denied due to the age or due to type of visit.
This is correct. You either received the limited services provided under the "Welcome to Medicare" wellness benefit and it was coded incorrectly, or you received a more comprehensive annual physical exam and it was coded correctly.
If you received the non-covered comprehensive annual physical exam, you can receive the covered "Welcome to Medicare" benefit later in the year but it still must be within 12 months of Part B enrollment. However, this will push back the date you can receive the next annual wellness visit.
CPT G0402 - Welcome to Medicare Wellness visit. Eligibility - All Medicare beneficiaries within the first 12 months of their Part B coverage effective date. Covered once per lifetime.
CPT G0438 - First annual wellness visit. Eligibility - Enrolled in Part B more than 12 months and not received G0402 within 12 months.
CPT 99396 - Preventive physical exam, age 40-64, established patient. Eligibility - Code not covered by Medicare.
CPT 99397 - Preventive physical exam, age 65+, established patient. Eligibility - Code not covered by Medicare.
So, am I to understand that Medicare will pay for one wellness visit per year as long as it has been over 12 months from the last one? So if I go to my internist, they won't pay for the gyn doc? And during this "wellness" visit the doc can't touch you??? What kind of idiocy is that? How can the doc tell if you are well if he can't look down your throat, into your ears or listen to your heart or touch any other part of your body? So basically it will only pay if you are sick. Isn't that the thing that having medical insurance is supposed to fix? My hubby has to go to the doc twice a year because he takes blood pressure and cholesterol meds. They won't give him a full year prescription. He went earlier this year under Medicare and although we found out the hard way that Medicare won't pay for a routine Hep C test, everything else was covered. We did get it recoded (thanks to help from here) and it was paid for. He has another appointment in 3 weeks. Are we going to get hit with a bill for that one? Or doesn't his visits count if he is on meds? He actually goes to a PA, but she does check him out and take BP, etc.
I am getting really confused by all of this. I thought Medicare was going to be easier. I am not dumb by any stretch, but this is ridiculous. I have a friend who is on Medicare and has the same Medigap as we do and she claims that between the 2 she has never paid a penny to any doc since she started with them. Now admittedly she is a diabetic and pays big time for her meds, but still.
So, am I to understand that Medicare will pay for one wellness visit per year as long as it has been over 12 months from the last one? So if I go to my internist, they won't pay for the gyn doc? And during this "wellness" visit the doc can't touch you??? What kind of idiocy is that? How can the doc tell if you are well if he can't look down your throat, into your ears or listen to your heart or touch any other part of your body? So basically it will only pay if you are sick. Isn't that the thing that having medical insurance is supposed to fix? My hubby has to go to the doc twice a year because he takes blood pressure and cholesterol meds. They won't give him a full year prescription. He went earlier this year under Medicare and although we found out the hard way that Medicare won't pay for a routine Hep C test, everything else was covered. We did get it recoded (thanks to help from here) and it was paid for. He has another appointment in 3 weeks. Are we going to get hit with a bill for that one? Or doesn't his visits count if he is on meds? He actually goes to a PA, but she does check him out and take BP, etc.
I am getting really confused by all of this. I thought Medicare was going to be easier. I am not dumb by any stretch, but this is ridiculous. I have a friend who is on Medicare and has the same Medigap as we do and she claims that between the 2 she has never paid a penny to any doc since she started with them. Now admittedly she is a diabetic and pays big time for her meds, but still.
I think by "touching you" the previous poster meant asking you to pay for the non-covered service. However, the wellness visit does not include a head to toe physical. It is designed to uncover risk factors and come up with a game plan to deal with them.
There is a definition for the wellness visit. You cannot discuss any problems at that visit. If you do, or the doctor picks up something abnormal, then it is not a "wellness" visit and you will owe a copay.
The gyn doc should not be coding the visit as a "wellness" visit. There are separate preventive medicine codes. There will be no copay if you meet certain criteria:
Your husband's visit should be covered. However, since it will be to manage his high blood pressure and elevated cholesterol it will not be a "wellness" visit. Expect there to be a copay.
I think by "touching you" the previous poster meant asking you to pay for the non-covered service. However, the wellness visit does not include a head to toe physical. It is designed to uncover risk factors and come up with a game plan to deal with them.
There is a definition for the wellness visit. You cannot discuss any problems at that visit. If you do, or the doctor picks up something abnormal, then it is not a "wellness" visit and you will owe a copay.
The gyn doc should not be coding the visit as a "wellness" visit. There are separate preventive medicine codes. There will be no copay if you meet certain criteria:
Your husband's visit should be covered. However, since it will be to manage his high blood pressure and elevated cholesterol it will not be a "wellness" visit. Expect there to be a copay.
Thanks for the info. I have no problems with copays as we have a Medigap F policy. I understood that there was a deductible and copays with Medicare and that's why we went with a Medigap. I did not understand that they could actually totally refuse to pay for a doc visit.
I actually went to the gyn office today and asked about it. After some checking the woman did tell me that the general visit would usually not be paid for by Medicare, but they forgot to have me a sign a form saying that and therefore would have to write off the $55 cost that Medicare didn't pay for if the Medigap doesn't pay either. I lucked out on that one but will be aware in the future and be careful about what happens at any doc visits. The only things I have happening are arthritis, hip replacement and diverticuli, so not sure any of that would qualify my visits to be paid. I only take 1 Rx med and that's for my back spasms. Everything else is OTC.
Having insurance is not for routine check ups etc. it IS for when you get SICK or INJURED. It may cover some routine things but that is not the main purpose of Health insurance.
Having insurance is not for routine check ups etc. it IS for when you get SICK or INJURED. It may cover some routine things but that is not the main purpose of Health insurance.
That is the exact opposite of the philosophy and practice of an HMO. It's called "preventative medicine."
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
