Insurance refuses to cover mammo

calamtykel

My doctor sent me for a mammo last June.  A small cyst was there, but when she looked for it in the office, it was gone (on the ultrasound).

I went back in January for what I thought was my routine post breast cancer mammo and it was not covered by my insurance company.  Called today - Aetna claims since it was "diagnostic" that it's not eligible for the 100 percent routine mammo coverage.  (the 100 percent coverage by the way is no limit, no deductible - as many mammos as I want a year).  But NOT diagnostic mammos.  HELLO - aren't they ALL diagnostic?? 

They advised me to call the diagnostic center and have it coded as routine.  The diagnostic center refused. 

Meanwhile, my husband's benefits coordinator said that nobody can recode it now, not even the doctor and that we owe the $356 unfortunately.  And will continue to have to pay for my mammograms in the future since I Have a history of BC; they will get coded as diagnostic.   I got off the phone and burst into tears and have been crying for over an hour.  We already owe nearly 6K in BC bills from last year - it's never ending.............

Can I just sound off here and say where the F does ANY Of the funding go to breast cancer/??  Where are all the laws for breast cancer patients??   I NEVER want to see another stinkin' pink ribbon - will NEVER race for the cure or give anything to breast cancer prevention.   Healthy women get free mammos.  If you have a history of breast cancer, you have to pay.  

kathleen1966

That's odd.  I also have Aetna insurance and I had no problem getting a diagnostic mammogram (it was actually my first mammogram).  I also got a mammogram in July.  This was considered a "routine" mammogram on my remaining breast.  I would have your doctor call and try to resolve this issue.  Do NOT pay that 356!!!! That is just outrageous. 

Sherryc

cala I know how you feel.  Although all my mammo's and ultrasounds are covered at 100%.  I am considered high risk with very dense breast tissue and mammo's are not relieable at all.  All my Dr's said I would need a MRI yearly and that is considered diagnostic by my insurance so my portion every year would be $1900 (duductible and out of pocket).  WTH I can't afford this on top of everything else.  Had another scare in my so called good breast so now I am going back and having BMX with reconstruction so I can scale down my medical bills.  Wish I would have been informed of all this up front.  I would have made different decisions. 

I also think your benefits corrdinator is wrong about the coding.  I had an instance with my husband where a doctors office coded a stress test for my husband for high cholosteral (which was not covered on our insurance) instead of the TIA that he had.  It took months of me following up on it but the Doctors office finally changed the coding and then the hospital could then change theirs and refile with the insurance company and it was all paid for.

Hope you get it resolved.

calamtykel

kathleen - my deductible is $2500 a year; so it was applied to my deductible.  Instead of being covered 100 percent.

 we're going to try to get it recoded but......  

 I'm just so done with this all.  We owe so much and it just keeps snowballing -everybody's got their hand out.  We are so in debt.  We pay a ridiculous amount for our premium; it keeps going up and up, with lesser and lesser coverage.  

velutha

1) call the radiologists office and ask to talk to their billing dept. politely and calmly ask for help.

2) call ACS and ask for help. Ask other local cancer charities if they can help with ideas.

3) if all else fails, ask the radiologist if they will negotiate payment directly with you, as you are paying, not the insurance company. If there is more than one group in town, haggle with both for the best rate. Ask the PHYSICIAN, by writing a letter to them. Keep it short and sweet, be clear about what you can afford and what services you need.

4) contact your nearest cancer center and ask for help. Most have patient navigators, many of whom are used to dealing with insurance.

kathleen1966

Yes, each year our insurance goes up and up, so much so that in the past five years our paycheck has gone down, down, down...Life is a struggle for us financially. I have been a stay at home mom..planned to go back to work last year and worked on fighting cancer instead.  I am looking for a job right now and having a LOT of trouble.  I haven't even managed to get one interview.  And these are not high-paying fast track career type jobs....It shouldn't be soo hard to get simple tests when we are paying soo much to have the insurance. Aetna fought a PET scan they wanted me to have in the beginning of treatment.  Due to low tumor markers and no signs of spread....I don't know what my oncologist told them, but she was mad she had to waste her time and got me in some how. However, this was the only time I had an issue and they have paid for mostly everything...even a wig....We owe about 1,500.00 right now...One time I added up the full cost of my treatment and it was over 500,000.00 dollars. Very sad.....and causes me great worry.

lhasamom

I am SO SORRY to hear of all the crap you have had to deal with!!!  Pick up the phone and call the hospital/diagnostic center, etc, and ask for the financial department.  Every hospital has a department that will work with you and can even get some bills either reduced/waved/ or make a payment plan.  If you don't ask, you won't know of the help you can get.  Call your hospital and ask for the cancer center and then ask for the nurse navigator, she will be able to give you support and help.

Sarahmfallon

Sounds like what happened to me. All my mammos are only covered at 80% because they are diagnostic. they will never be considered routine until I am 35 (I am 28). I argued many times with Aetna that they are routine because my doctor prescribed it and I have the BRCA gene. They said it is diagnostic and will remain that way until I am 35. Routine mammos are covered 100%. Last time I went I told the hospital to code it as routine so my insurance would pay. They did and it was denied by insurance saying I didn't fit the age criteria. That mammo showed I had cancer at 28 and I didn't fit the age criteria?!? I asked the hospital to re code for diagnostic, went through a lot of back and forth. They said they dud, new claim still shows it as diagnostic and I owe $375. I don't have the energy to call again and again and fight it. This was in September, I still haven't paid it. I'm going to set up a payment plan for like $50/month. Ridiculous. My Aetna deductible is 400, out of pocket max is 2000 for myself and 4000/family. I already hit about half that before my BMX/DIEP surgery a couple weeks ago so the whole surgery and hospital shooing only be $1000 to meet my out of pocket max and then everything is covered 100% through the end if the year.

peggy_j

FWIW, it looks like I have the same prob, that my new "diagnostic" mammos aren't covered 100%. Previously they were covered under the special Well Woman Clause (I wonder if our good pre-BC coverage was due to the Health Care Act of 2010 that requires coverage for preventative care)

FWIW, we have a low deductible and this amount goes towards it, so if I'm healthy this year I'm going to be happy. If I need doc appts, I'll be hitting that deductible soon enough and this extra co-pay will be a wash anyway.

calamtykel

To me, this is where "awareness" money should go - exposing what insurance companies do to BC patients.  I made many phone calls, even appealing to my physician, who called me back and said that she can't change the diagnosis code - everyone's hands are tied. 

My out of pocket is $2000 -- we still haven't paid for the mammo in January and now they are threatening collections.  We simply do not have the money after these past two years of medical bills.   

What I really do not understand is that they would cover 100 percent of a REGULAR mammogram outside of the deductible, but 0 percent of a diagnositic.  Could not they at least cover PART of the diagnostic since I'm not having regular ones??  

I wish we could afford a 100 percent plan through my husband's company but we simply cannot - it's ironic that those who make more money within the company can afford the better care plan, while those of us on the bottom are stuck paying most of our medical out of pocket.  There must be a better way!

Sarahmfallon

@Calamtykel - I know exactly how you feel.  Thankfully my diagnostic ones are covered at 80% but I still fully believe they should be covered at 100%, especially when I didnt have cancer, just the gene, so it was preventative!  My doctor didnt change the code either.  It ended up being $375 for my mammo back in September. I waited until this past week when I got the threatening collections letter then called and told them I needed to make payments. I  said I could do $25 a month and they were fine with it.

Id try calling and just saying you need to set up a payment plan.  Im also doing that for my MRI that was $1000 (to reach the rest of of my $2k out of pocket max) and am making $50 payments each month.  They cant add any interest on it so if it takes me almost 2 years to pay them back, oh well.  Most facilities and hospitals will work out a payment plan with you, some as low as $10 per month!  Good luck!

omg333

Just read your rage Calamtykel, I feel badly, and I do hope you get answers!  It's all a crazy shame, and you and many are victims to the "coding" also.