Preventive screenings are covered by Medicare at no cost to the patient, but sometimes there will be a bill to pay.  A colonoscopy is the example I use with my clients to explain how “free” tests and procedures sometimes turn out not to be free.

Last month, a client called me to complain about a bill she received for her colonoscopy. “Should I pay this bill?” she asked. “I thought this test was supposed to be free!”

My quick reply to her question was, “Yes, you must pay that bill”. Then I said, “They found polyps and removed them, didn’t they?”  She wondered how I could know the results of her colonoscopy, so I told her how a free screening can turn into a billable procedure.

A preventive screening colonoscopy is “free” to the patient – but when the doctor finds polyps and removes them, that preventive screening procedure turns into “outpatient surgery”. This client told me her bill was $250, and sure enough, her Medicare Advantage plan has a $250 co-pay for outpatient surgery. This is how I deduced that polyps had been found and removed during her colonoscopy.

Here is the list of preventive screenings covered by Medicare at no cost to the patient. I’ve highlighted the most common ones.

Abdominal Aortic Aneurysm Screening

Alcohol Misuse Screening and Counseling

Bone Mass Measurement (Bone Density Test)

Cardiovascular Disease (Behavorial Therapy)

Cardiovascular Screenings (cholesterol, lipids, triglycerides)

Colorectal Cancer Screenings

Depression Screening

Diabetes Screening

Flu Shot

Glaucoma Test

HIV Screening

Mammogram (screening for breast cancer)

Obesity Screening and Counseling

Pap Test and Pelvic Exam (includes a breast exam)

Prostate Cancer Screenings

What terrible things has “Obamacare” delivered since the Affordable Care Act was passed in 2010?  According to the Center for Medicare Advocacy, here is how the healthcare reform law has affected Medicare:

• Closing the Medicare Drug Coverage Gap. 2011 is the first year of a multi-year phase out of the “donut hole”.  For 2011, beneficiaries pay only 50% of the cost of brand name drugs in the donut hole and 93% of the cost of generic drugs.
• Medicare Preventive Services. This provision requires Medicare to eliminate cost-sharing for Medicare-covered preventive services rated as A or B by the U.S. Preventive Services Task Force. It also waives the Medicare deductible for colorectal screening and authorizes coverage for an individualized prevention plan.
• Changes to Increased Medicare Premiums for Higher-Income Beneficiaries. Since 2007, Medicare beneficiaries with incomes above a certain level have been required to pay higher Part B premiums. The ACA froze the income level at which such premium surcharges apply at $85,000/year through 2019 and expanded the surcharge to also apply to Part D premiums.

• Medicare Extra Payments. For the years 2011 through 2015, Medicare will pay a 10 percent bonus for primary care services; it will also pay a 10 percent bonus to general surgeons practicing in areas with a shortage of health professionals.
• Medicare Advantage (MA) Payment Changes. Beginning in 2011, Medicare Advantage payments are restructured at an increasingly smaller percentage of original Medicare rates. Prior to the restructuring, MA payments were, on average, 13% higher than those for traditional Medicare. Also beginning in 2011, MA plans are prohibited from charging higher cost-sharing than original Medicare for skilled nursing facility care, chemotherapy and kidney dialysis.  In 2012, MA plans with four or five stars on a five star quality rating system are entitled to bonuses. The Centers for Medicare & Medicaid Services has expanded the bonus payment program to include plans with three stars. NOTE: This is good news for MA plans in Arizona!

• Medicare Independence at Home Demonstration. This provision creates a demonstration program to provide high-need Medicare beneficiaries with primary care services in their home.
• Medicare Value-Based Purchasing. Beginning October 1, 2012, Medicare will pay hospitals based on their performance on certain quality measures and will move toward making such payments applicable to skilled nursing facilities, home health agencies and ambulatory surgical centers.
• Reduced Medicare Payments for Hospital Readmissions. Beginning October 1, 2012, Medicare will reduce payments to hospitals for preventable readmissions within 30 days.
• Data Collection to Reduce Health Care Disparities. Effective March 23, 2012, the ACA requires the collection and reporting of certain data on race, ethnicity, sex, primary language, and disability status.

Healthcare reform now requires health insurance to cover preventive screenings at no cost to the patient. (I am talking about under-65 health insurance, not Medicare.) That means an annual visit to a primary care physician, nurse practitioner, or a physician’s assistant.

Note: The new rules apply to new health insurance plans or insurance policies that began on or after September 23, 2010.

People are encouraged to get these screenings even if they have a high-deductible health insurance plan. But it turns out some people have been surprised to find their free visit to the doctor resulted in a substantial bill. The surprise bill is due to the doctor going beyond the annual consultation and providing additional services, such as discussing symptoms that would require a diagnosis of a problem.  Apparently this is beyond the scope of a consultation for a physical, and results in the doctor generating another bill – something the insurance company is not required to pay if the patient has a plan with a deductible that has not been met.

In Connecticut, two patients filed complaints with the state’s Attorney General when they got surprise bills from what they thought were annual physical consults with their primary care doctors. They assumed they would have no co-pay for the visit to the doctor.

According to an article in The Day newspaper in New London, Connecticut:

[Doctors] are able to tack on these extra fees because there are no set guidelines by the American Medical Association or any other medical body that specifies exactly what an annual physical should include. This permits doctors and medical practices to unilaterally decide what is included and what they can bill for extra.

“We discovered,” said Attorney General spokeswoman Susan Kinsman, “that the threshold determination of when significant additional services are rendered is made largely on a case-by-case basis and … appears to permit services that may seem minor to a layperson, to be considered significant to a physician or billing agent.”

The two patients in Connecticut who complained were put on a “do not serve” list by the Hartford Medical Group, which is one of the largest medical practices in the state of Connecticut. They got some vindication from an investigation by the state’s Attorney General. The Hartford Medical Group agreed their doctors should advise patients when an examination goes beyond the scope of a preventative wellness exam that would generate another bill.

Medicare now covers more preventive services.

Seniors are being encouraged to take advantage of these “free” Medicare benefits. But they might be surprised to find they actually need to pay something because of the scope of the appointment with their doctor.

A client of mine said she was surprised to get a bill for a $40 co-pay when she went for her annual exam with her gynecologist.  She is enrolled in a Medicare Advantage plan. As we talked about the bill, she told me she has a particular female condition  – and I surmised that the doctor was doing more than an annual exam, which resulted in the co-pay to see a specialist. My client was not upset with the co-pay, but she was happy to understand why she had to pay it.  Of course, this information probably should have come from the doctor rather than an insurance broker.

The list of preventive services covered by a person’s health insurance can be found at http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html  This is not the Medicare list.  This is for people under 65.

For a list of Medicare-covered preventive services look here: http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx