If you have Medicare, we know that billing can be confusing. This information will help you better understand how Medicare pays for gynecologic and annual (preventive) exams.
Preventive pelvic exams and physical breast exams are covered by Medicare once every two years. If you have a pelvic exam before 23 months, Medicare will deny the charges and you are likely to become financially responsible for the full cost of these services. There may be exceptions. If you are considered a high-risk patient, Medicare will cover these services on a more regular basis (for example, annually). Some factors that could place you in a high-risk category are:
- Becoming sexually active before 16 years of age
- Having five or more sexual partners in your lifetime
- Having a history of sexually transmitted diseases
- Fewer than three negative Pap smears, or never having a Pap smear, during the previous seven years
- Exposure to Diethylstilbestrol (DES) in-utero
While Medicare may cover the pelvic exam, other services performed during your visit may not be covered. Medicare does not cover annual preventive physicals that may include a more thorough physical exam, review of medical history, and counseling (such as advice on nutrition, smoking and exercise). Please note that we are bound by federal law to follow these guidelines and cannot make alternative arrangements with Medicare.
If you are seeing your provider for preventive services as well as on-going health problems, such as diabetes, high blood pressure or other conditions, this portion of the visit is generally covered by Medicare Part B and will be billed separately. You may still have some patient responsibility for non-covered services and cost share.
As a courtesy, we bill Medicare for these services on your behalf. If Medicare will not cover these services based on frequency, or other requirements, it is at this time that your secondary insurance, if you have it, will be billed. Please note, your secondary insurance may or may not cover these services as well. Please contact them directly for coverage questions.