Preventive Services and Medicare

I had a call yesterday from a client who got a bill from her gynecologist.  She has a Plan F Medicare supplement and I have told her she should never get a bill – because Plan F fills every gap in Medicare.  If Medicare pays the bill, her Plan F supplement will pay her co-insurance or deductible. I have told her to call me if she ever gets a bill.

Sally got a bill from her OB-GYN, so she called me.

Medicare pays for a pap smear every 24 months, but Sally is accustomed to getting one every year.  Sally turned 65 about two years ago and I guess she got a second pap smear in less than two years….so Medicare rejected the bill for this preventive screening. 

 I have written before about how Medicare covers preventive screenings and how often they will pay for tests.

From the Medicare.gov website:

For women with Medicare who are considered at low risk for cervical or vaginal cancer, Original Medicare covers 100 percent of the cost of one Pap smear every two years (24 months).

Medicare will  cover a Pap smear once a year for women who are considered at high risk of developing cervical or vaginal cancer.

I asked Sally if she is in this high-risk category and she said she had breast cancer several years ago.  I told her to talk to the doctor’s billing person to see if they will change the coding from “preventive screening” to “diagnostic”if they think she is high-risk .

I then got a call from someone at Sally’s OB-GYN office who said the bill was sent to Medicare with a billing code that indicated the patient had had breast cancer.  But, she said, “because the patient is not currently being treated for breast cancer”, Medicare would not pay for the pap smear done less than two years since the previous one.

The woman who called me from Sally’s OB-GYN office said Medicare Advantage plans do pay for a pap smear every year.  That surprised me since they usually follow Medicare rules and restrictions, especially when it will save them money.

I tell my clients who get a Plan F Medicare supplement that they shouldn’t get any bills for medical services.  But I always emphasize, “If Medicare pays the bill, the Plan F Medicare supplement must pay its part.  But…. if Medicare does not pay the bill, the supplement doesn’t pay either”.  That’s what happened to Sally in this situation.