General Screening rules: Medicare

Title XVIII of the Social Security Act, section 1862 (a)(7) excludes routine physical checkups (including tests that are performed in the absence of signs or symptoms) from reimbursement by the Medicare program.  Screening exams/procedures are defined as examinations and/or diagnostic procedures performed in the absence of signs and symptoms.  Screening is often performed based on patient age, and/or family history.  While election to perform such examinations and tests may be considered good medical practice, they are not covered services under the Medicare program.

Health and Wellness Screening

Medicare generally does not cover health and wellness education and you are responsible for all costs.

Welcome To Medicare Visit

The Medicare Modernization Act, section 611, provides Medicare coverage for an initial preventive physical examination for new beneficiaries.   Here is what this visit covers according to Medicare:

• The term "physical exam" is misleading because it is really a "health assessment".  There is no covered examination covered by the visit except for documentation of your vital signs and a visual acuity test.
• This visit is more like an interview to determine your health risk factors and to expalin what preventive benefits are available (see list below).
• Covered services:
  • Review of your history for risk of depression
  • Electrocardiogram
  • Education, counseling and referral as appropriate based on the results of the history
  • Mammography once per year
  • Colorectal screening/fecal occult blood testing
  • Colonoscopy for high risk individuals
  • Pelvic and breast exams every two years
  • Prostate cancer screening/digital rectal exam yearly
  • Prostate cancer blood testing (PSA) yearly

 Annual Examinations:  The following are considered Non-Covered Services

• Routine examinations (annual examinations) and tests directly related to such exams
• Routine foot and dental care
• Immunizations except for the Flu, pneumonia or Hepatitis B
• Prescription drugs
• Cosmetic surgery

For these services Medicare expects the doctor to bill you directly and you are responsible for the payment. 

Medical necessity means that Medicare only pays if you have signs or symptoms of illness.  Sometimes your visit can be both routine and medically necessary.

Note from Dr. Howard

"I realize this may be different than what you think or how things have been done in the past.  However, these are the guidelines from Medicare and are available online for your review.  I believe that every patient in my practice needs to have a comprehensive review of their history, have a a physical exam  performed and have appropriate screening tests ordered even in the absence of disease.  I believe prevention is even more important than just treating disease.  There is a charge for this service and all patients are required to pay their portion after Medicare is billed."

Cost: $350.00.

This does include screening bloodwork not covered by Medicare.*  The cost of the bloodwork alone exceeds $100.00 in most cases.  I believe this is a valuable service. 

If you are not interested in comprehensive care then my practice may not be the right one for you.

*Only if blood is drawn at Quest Laboratories and listed on Dr. Howard's account