Sometime things happen in our healthcare journey that leave us wondering, “What am I supposed to do? Who do I call? How am I going to handle this?” Other times, we don’t even know that we should be asking questions. The next several posts will address situations that can leave patients financially responsible - simply because sometimes we don't know what we don’t know.
What do I do if the mammogram comes back with dense breast tissue and the doctor orders a second exam?
The Affordable Care Act (ACA) requires most health insurance companies to pay for screening mammograms with no out-of-pocket cost for women ages 40 and older. The law does not apply to women below the age of 40, and it covers only one screening test per year.
The conversation with the doctor’s office usually goes something like this,
Provider: Your mammogram came back indicating you have dense breast tissue. It’s nothing to worry about. The doctor just wants to order a second exam to be safe.
Patient: All right, what do I need to do?
Provider: We will send the order. The facility will contact you. If you don’t hear from them within 48 hours, go ahead and give them a call to schedule. We will contact you again after the results are received and the doctor has reviewed them.
When this situation occurs, the insured patient often assumes the second mammogram will be covered under the preventative care benefit. However, in most states when a second exam is ordered, that second mammogram will NOT be covered under the 100% preventative care benefits. This means a deductible and/or co-insurance will likely apply, and the patient will be responsible for the cost of the second exam.
Before scheduling a second mammogram, discuss with your provider whether you will be getting a 2D or a 3D mammogram. Let your provider know you are going to call around and check prices. The difference in cost between various facilities can be significant. If checking prices for a 3D mammogram, be specific. Not all facilities are equipped to provide 3D service.
Pro tip: It may shorten your search to know that as a general rule free standing facilities are often less expensive, and mammogram facilities connected to a hospital are usually more expensive.
Check the cash price. How much would your mammogram cost if you didn't run it through your insurance? Then check your cost if you ran the mammogram through your insurance plan. The facility will need information from your insurance card, so be sure to have it available!
If you plan on running a mammogram through your insurance, confirm that the facility is in-network with your specific insurance plan (the insurance company AND the contracted provider network). Most insurance companies are connected with several networks, but medical providers are rarely contracted with all of them. Use these words:
"Are you contracted with my insurance plan?"
Again, the provider will need the information from your insurance card, so be sure to have it available. Medical providers take or accept almost all insurance, but this does NOT mean a medical provider is contracted and in-network. The difference is YOUR hard earned dollars.
If you choose to pay cash, understand that what you spend will NOT accumulate towards your insurance deductible or annual out-of-pocket maximum. Sometimes the price difference is substantial. If you don't think you are going to meet your deductible and annual out-of-pocket maximum for the year, you might choose to pay cash anyway.
What do I do if the doctor orders a Breast MRI?
Some medical professionals recommend MRIs for women at higher risk for breast cancer. Woman need to be aware that preventative MRI scans are not subject to the ACA’s preventive services coverage requirement. Unless state laws mandate coverage, or the insurance company has preauthorized a preventative MRI, a deductible or co-pay will almost certainly be applied.
A little time shopping might result in a substantial savings. Call around and compare the cash price and the insurance price before selecting a facility.
If you are at a high risk for breast cancer, check with your insurer. You and your medical provider may be able to appeal and get your preventative MRI covered.
If genetic testing has uncovered a propensity towards breast cancer, sharing those results with your insurer could result in your insurer providing coverage for additional preventative measures - including preventative MRIs.
The lab comes back indicating there is a spot on the x-ray and a better film is needed to take a second look?
When the doctor’s office calls and tells you they need a better film, you likely assume something went wrong and they are going to do it again. You also probably assume that the repeated mammogram will be covered by your insurance - just like the first one was. Often the patient gets that second mammogram completely unaware that in a few weeks they will almost certainly receive a bill.
Before agreeing to a repeat, ask questions.
Why was the firsts x-ray not sufficient? Was the film bad? Was the image blurry? Did the X-ray tech not do a good job? Why is another image needed, and who is paying for this second image? The more you know BEFORE the test is done, the better position you are in to negotiate. At the very least, if you know that you are going to have to pay the bill, you can shop and find a cost effective facility. Don't forget to check the cash price if you pay upfront rather than running the claim through your insurance. While it won't apply to your deductible and out-of-pocket maximums, the difference might be significant enough that you choose to pay cash anyway.
Too often a patient needs a second image and can’t pay for it, so they don’t have it done. This puts their health at risk and eliminates the chance of early detection.
freemammograms.org is one of many resources that can help you locate clinics and facilities that provide free mammogram and other diagnostic procedures for women at little or no cost.
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