How to Get Medicare to Cover a Regular Physical Exam

How Medicare Part B Works

Medicare Part B covers many preventive care screenings and examinations , including pelvic exams and Pap smears, mammograms, bone density testing, colorectal and prostate cancer screening, diabetes screening, and glaucoma testing. With regard to regular physical checkups, in 2010 it covers only an initial "wellness examination" within the first six months of enrolling in Medicare Part B but not an annual comprehensive physical exam. (Many Medicare Part C [Medicare Advantage Managed Care Plans] do make such regular exams a part of their coverage.)

Beginning on January 1, 2011, however, the new healthcare reform law allows Medicare Part B to greatly expand its coverage for regular physical exams. As of 2011, everyone enrolled in Medicare Part B is entitled to one "wellness" physical examination annually. This is a thorough exam that includes a comprehensive health-risk assessment, which may include further laboratory or other testing.

Until 2011, Medicare's noncoverage of regular physical exams can put you in a bind. You can get a regular physical exam by paying for the expensive doctor and laboratory work out of your own pocket (if you can afford it). Or you can skip the exam and risk missing the kinds of early disease detection that makes such exams so important.

But there may be a way out of this bind. If you haven't had a thorough physical examination for a while and would like to have Medicare cover one for you, here's how to do so without breaking Medicare rules:

Medicare Part B currently does cover an examination by your doctor, plus related laboratory work, X-rays, and diagnostic testing, to investigate a particular health problem or complaint. And, like most people over 65, you probably have at least one or more minor physical complaints or problems about which, ordinarily, you wouldn't make a special trip to the doctor. On the other hand, if you had a general physical examination and your doctor asked you about any problems or complaints, you would likely mention these. The trick to getting Medicare to pay for a general physical exam is to make these minor complaints the subject of a doctor visit. This turns the doctor's investigation of these problems -- which can include a fairly broad examination plus laboratory or other diagnostic work -- into a Medicare-covered service, as long as the exam and diagnostics are reasonably related to the physical complaints you have reported.

The Four Steps to Getting Medicare to Cover a Physical Exam

1. Call your doctor's office to make an appointment. When the person scheduling the appointment asks the reason for your visit, mention the conditions or symptoms that are bothering you. Do not ask for a regular physical examination.

2. When you see your doctor at the visit, begin by explaining the problems or symptoms that have been bothering you.

3. During the visit, remind the doct or that you have not had a physical examination in a while (your medical records will tell the doctor exactly when) and ask if he could give you as broad an examination as possible related to the symptoms or complaints you have mentioned.

4. You might want to mention to the doctor your concern that the examination and testing should meet Medicare coverage requirements . Doctors are very experienced with Medicare coverage rules and know how to describe your examination and testing in a way that places it under the Medicare umbrella. But it's up to you to give your doctor the chance to do this by presenting the doctor with specific complaints rather than merely asking for a physical exam.

Joseph L. Matthews

Joseph Matthews is an attorney and the author of numerous books, including Social Security, Medicare, and Government Pensions, Long-Term Care: How to Plan and Pay for It; How to Win Your Personal Injury Claim; and The Lawyer Who Blew up His Desk. See full bio

almost 2 years, said...

Doing this severely impacts the doctor's scheduled appointments, thus the following patients. In fact, my doctor requires that patients schedule an appointment specifically for a physical. She knows the Medicare rules and mine have always been covered.

almost 2 years, said...

This is idiotic. If you make an appointment and say "I have a headache" you get insurance coverage for it. If you say "I want to make sure I'm not ill" you don't get coverage. Typical government bureaucracy. If you are "in the know" you're covered. If you're a average person, you're not. This is why citizens hate government (socialized) medical insurance.

about 2 years, said...

does medicare pay for DOT/CDL yearly exams? Since I am over 65 I have to have it every year!

over 2 years, said...

I am on medicare and Medicaid so is it mandatory to have pap smears to keep medicare or do they take it away from you if you refuse. im 69 and don't feel comfortable about the situation

over 2 years, said...

Medicare should include a yearly physical covering at least blood work , kidney function, HDL, LDL, etc. why it doesn't is onerous.

over 2 years, said...

Yes this is fraud. Annual routine visits for medicare are not at all based on generilzef complaints. See annual wellcarevisit form and intake from your local Cms site. I can't beieve you would advise a patient to lie and be deceptive to their doctors office when making the appt. "Withhold the fact that you are coming in for your andnual Wellcare visit" and then the patient gets a $200.00 bill!!! Horrible advice!!!!

almost 8 years, said...

Another term for this clever little trick is "insurance fraud". Oh, wait, this is regarding Medicare. That then also makes it "filing a false claim with the government" and is therefore subject to the "False Claims Act". Physicians DON'T know about the rules - if they did, they'd tell you to make a separate appointment for the well visit and pay in cash.