Medicare was originally intended to assist elderly Americans in paying their medical bills and not as a comprehensive health insurance plan. Nevertheless, Medicare has emerged as the only source of medical insurance for many Americans. However, Medicare does not normally cover "routine" medical care, including an annual physical exam and most preventive health services. Medicare will only cover those services that Medicare deems as "medically necessary". Many people interpret medical necessity to mean...."If my doctor ordered it, the test must be 'medically necessary' ". Unfortunately, Medicare and your doctor do not always agree on what is "medically necessary".

Medicare policy has changed over the years such that Medicare now does pay for SOME routine (preventive) health care services. For example, Medicare will pay for a routine mammogram (provided the test is not performed more frequently than allowed by Medicare guidelines). Medicare covers the following preventive health services as of January 1, 1998:

• Mammogram annually for all women over 40 years old.
• Pap smears, pelvic exam every 3 years for low risk women, every year for high risk women.
• There are 3 tests covered by Medicare to screen for colon cancer. A hemoccult test (collect 3 stool specimens that are tested for blood by your doctor) is covered every 12 months if you are over 50y/o.

A flexible sigmoidoscopy (flexible tube inserted into rectum looking into approximately the last 2 feet of the colon for evidence of cancer) are covered every 48 months if you are over 50 y/o.

A colonoscopy is a covered procedure only if you are at high risk for colon cancer.

• Blood glucose monitors and test strips for all diabetics

On the other hand, Medicare will not pay for prostate cancer screening (although they may do this starting in January, 2000) or for a screening chest x-ray looking for lung cancer in asymptomatic smokers.

Although Medicare has never officially paid for routine care (which includes an annual complete physical exam and any routine laboratory studies, X-rays or electrocardiograms) when you went to the physician solely for this purpose, Medicare would pay for these routine visits if you also had some other identifiable medical problem(s) (for example, high blood pressure). HOWEVER, recently Medicare now requires physicians to bill for the routine part of the visit separate from the "medically necessary" part of the visit. If your physician does not abide by these rules and bill you for the routine part of the office visit, your physician may be accused of trying to defraud the federal government. For this reason, you can expect to be responsible for a greater portion of your health care costs.

If you have high blood pressure and diabetes, you may normally see your physician 4 times per year to monitor these medical problems. During one of your 4 yearly visits to your physician, it is likely that your physician may elect to perform an "annual exam". As part of an "annual" exam, your physician will perform a more detailed physical examination which may include a rectal examination (in men) or a pelvic examination (in women). Your physician may also decide to order some routine blood work, an electrocardiogram or a x-ray. Many physicians feel these tests are important in the maintenance of good health. Ordering these additional tests may be based on your family history or on certain lifestyle factors (smoking cigarettes, drinking alcohol) and not specifically related to your medical problems (in this example, diabetes or high blood pressure). When your physician sees you, your physician charges Medicare based on how difficult your medical problems are to manage. The charges range from a level 1 office visit (indicating a very simple problem) to a level 5 office visit (indicating a very complicated problem). Continuing in this same example, let's say that the work involved in managing diabetes and high blood pressure usually warrants a level 3 charge. When your physician is seeing you for the "annual exam", obviously more work is required at that visit even though your medical problems (the diabetes and the high blood pressure) are stable and unchanged from previous visits. One might expect your physician to bill a level 4 for this visit to the doctor (when the annual exam is performed). In the past, this was a common practice and considered appropriate by Medicare. HOWEVER, now Medicare insists that your physician split out the routine services (the annual exam and the routine laboratory and x-ray studies) from the "medically necessary" services (the management of your diabetes and high blood pressure). As you can imagine, it is difficult to divide up an office visit in such a way. Nevertheless, Medicare expects your physician to use his/her best judgement in making this determination. You (or your supplemental insurance if applicable) will be responsible for 100% of the bill for the "routine" portion of the office visit.

In the past, your physician appropriately billed Medicare a higher level of service when you had your "annual exam". Now, your physician is legally obligated to use his/her best judgement in determining what portion of your visit was "medically necessary" and what portion of your visit was considered "routine" medical care (including most preventive health care services like an annual physical exam, certain laboratory studies, an electrocardiogram, or a chest x-ray). Unless you have a supplemental insurance plan that pays for "routine" health care services, you will be responsible for paying 100% of these services that Medicare does not cover. These changes mean that most Medicare patients will be responsible for paying a larger portion of their health care costs.

FURTHER INFORMATION

Our business office (located on the lower level of our building) would be happy to try to answer any additional questions you may still have. We will attempt to get your insurance to pay for those services that should be covered. If you still have unanswered questions you may contact Medicare directly by calling 1-800-532-1285.