Diagnostic mammogram

Ginger12

Hello, I'm not sure what to do about a problem I am having...I hadn't had a pap a few years and finally in late 2012 I did, my gyn said I need to have a mammogram because my sister had just went through breast cancer and so it put me at a higher risk than normal. I was 39 at the time and worried about the cost, they told me it would be preventive cause I have a family history of cancer. So I went to a diagnostic center and had one it came back abnormal and they did an ultrasound, It showed up 3 lumps. I ended up having biopsies on each lump in Jan 2013. It turned out to be friboadenoma. I had to have a followup mammogram in April 10, 2013 came back good and they told me I wouldn't have to have another one til a year from then. So last month I got a card in the mail from the diagnostic center telling me I was overdue for my annual mammogram (like 2 weeks). So I called them, they told me to call my gyn and have her to set it up, I did. I had my mammogram in April 21, 2014. I got a bill the other day for $450 for the mammogram. I was in shock cause I thought it was suppose to be 100% covered by our insurance (Blue Cross of California, but I live in KY). I called the diagnostic center cause that's who billed me, they said it was diagnostic and the gyn doctor who was the one who coded it that way. Funny thing I hadn't even seen my gyn since 2012...I called the doctor, they said there wasn't anything they could cause they didn't bill me, and it was the diagnostic center who billed me..I tried to tell them the doctor was the one who coded it that way not them and they said there wasn't anything they could do. I called the insurance, they told me it was because it was diagnostic and not screening. I told them NOT one person EVER told me before I got the mammogram that it wouldn't be covered by my insurance. She said they're suppose. Anyway, the insurance is going to appeal it and see if they can't get took care of. I am so upset cause NO ONE told me my insurance wouldn't cover diagnostic, heck I never knew there was a difference. I thought as long as it was a mammogram once a year it's considered preventive. Get this, my gyn's office also said they didn't have that I had a mammogram in 2013 on their file..I don't feel I should pay this bill, I wasn't told by anyone that my insurance might not pay for it...I never even saw the gyn's order for this mammogram, she faxed to the diagnostic center.

crabbiepattie

I'm so sorry you got caught in this insurance trap.  My several diagnostic mammograms were no different than regular screening mammograms as far as I can tell, except I got an "all clear" before I left the office.  But insurance processes them quite differently.

Your insurance should, and probably will, cover the diagnostic mammo but not as a preventative service, meaning deductibles and co-pays apply.  Did your doctor's office intend to code a diagnostic mammo or not?   I really hope your appeal goes through!

Ginger12

Insurance said the doctor didn't code it as preventive but it was also coded for a diagnostic test, so if it were coded as preventive it still wouldn't make no difference cause the insurance doesn't cover diagnostic.. The center where I had the mammogram said they don't have to tell anybody if it's a diagnostic mammogram before they have one....I feel like women who have issues with their breasts are being discriminated against. It's not our fault...I feel like no matter what I do or who I talk to it's not gonna change anything. SOO unfair.

Ginger12

This is what it says 

total charges $1,035

patient payments $0

adjustments: -$592.94

account balance: $442.06

Ginger12

Well, I just found my last mammogram results from april 2013 and called the doctor they said they found it when the other day I was there showing them my bill, they couldn't find it on file. Anyway, on my results papers it says recommendation: normal interval followup......what does this mean, basic screening mammogram or?

april485

It means a one year interval with a normal screening mammogram...not diagnostic. Diagnostic is different due to the magnification and possibly some extra views instead of the normal screening mammo.

 Seems like someone messed up and they are putting it on you to clean up. Your doctor just needs to say that it was coded incorrectly and it will likely get covered. Strange that someone won't own up to the mistake but then again, nothing surprises me these days. So much incompetence! Hugs and hope they fix it for you.

Ginger12

shew, what a mess.....I had the insurance to appeal this and called the diagnostic center yesterday to let them know, they put a hold on the bill for 45 days. I have lost all trust in my doctor and the center.

chi-girl

Hi,

I'm in the same boat and am hoping that someone can help who has been through this. I have High Deductible Insurance. Everything except for preventive care comes out of my pocket. I had BC in 2012 so I get 2 diagnostic mammograms each year. (at least for now.) Last year one mammogram was paid for by my insurance and one I paid for myself. This year I've been billed for both.

Shouldn't my insurance cover the cost of one mammogram. (Or at least the equivalent of the cost of a preventative mammogram.)

I understand that it has to be coded as diagnostic, but I'm hoping that there's a way to get the Insurance company to pay for the preventive part. Otherwise, I'll be paying for mammograms for the rest of my life while they're covered for everyone else and that doesn't seem right or fair.

Anyone else have any luck on getting this resolved? Or have a solution? Anyone else have a High Deductible plan and dealing with this?

Moderators

Hi chi-girl-

Firstly, welcome to Breastcancer.org, we're sorry for the circumstances that brought you here, but we're glad you found us.

Your insurance should cover one screening mammogram every year, if you're over the age of 40. The Affordable Care Act made that a mandate, although some plans are grandfathered in and are exempt. Definitely contact your insurance carrier to make sure your plan covers preventative care. Also, talk to your provider, and make sure they're billing one of your mammos as an annual, preventative screening, and the other as diagnostic. Per recommended guidelines, women over 40 should have a mammogram every year. If your plan is one that was NOT grandfathered into the preventative care mandate, then at least one of your mammos should be covered, and perhaps your provider is billing both as diagnostic.

Please let us know if you have any questions! We're sure other members will be around shortly to offer their advice.

The Mods

chi-girl

Thanks!

I talked to my insurance company and they said it needs to be coded as preventive and routine in order to be covered. I asked and unfortunately they wouldn't give me which codes to use. (They said the doctor should know.) I'm currently talking to my doctor to see if she can get it recoded and then resubmitted.

Hopefully they'll get it resolved.

Since its mid-November, anyone know what happens if I don't get this resolved by Dec 31st? Can I still work to resolve in 2015 or do I miss out and it becomes my mammogram for 2015? That's got me worried as well.

chi-girl

Hi,

I'm still trying to get this issue resolved. Its been a year since I started trying. Its extremely frustrating.

Has anyone else had a problem with insurance not covering their diagnostic mammogram at 100% (free?) I have high deductible insurance so the hospital keeps telling me that I haven't met my deductible. I keep telling them that it should be "free" because my insurance covers 1 mammogram each year as long as its coded as routine. The insurance company won't tell me how to code it and the hospital is reluctant to resubmit.

I will take any help I can get.

Thanks!

Kafkasrecruit

Joined breastcancer.org specifically to look for issues like yours. I have not had a BC diagnosis. But, I have experienced the issue you describe with Insurances denying coverage for "diagnostic" mammograms. I don't know, but believe, the insurance company codes or corrects coding for tests, screenings, etc. I believe, but do not know, that this policy of covering older type screenings but denying coverage for digital or diagnostic mammography is one of probably a number of ways the insurance industry is attempting to circumvent those portions of the Patient Protection and Affordable Care Act that address preventative care.

I was sent for screening. Images inconclusive due to tissue density/margins. I was told the image was bad or unreadable because of this density, which could be cancer, but could not be determined. It is common for older women, which ironically, are those women over 40.

I was sent for digital mammography and the staff scheduling that appointment did an excellent job scaring the holy h*** out of me. Got a bill for radiology, facilities, and the visit. Not covered by insurance. Results from images were "image from regular screening inconclusive; no breast cancer worries found through digital."

Appealing may or may not work. I suspect it will not. I did not try because I was pretty sure the ICD-9 or ICD-10 coding would not help my case. Even if it was changed to preventative screening, only one preventative screening is covered per year. A re-coded digital mammography would be the second.

The insurances (Blues, for certain, maybe others like Aetna, United Health, etc) do NOT cover diagnostic tests and procedures under Preventative Health, and only one screening per year for women over 40 is covered. And, two entities stand to profit from this coding and billing practice -- the insurance company and the provider(s). You and I are on a decidedly uneven playing field.

We need lobbyists to convince legislators to address this loophole. As technology improves, the insurance coding and health care laws will not keep up. There is no incentive on the part of Insurance Lobbyists to address this failure to cover breast cancer screening on our behalf -- they are lobbying on behalf of a profit-driven insurance industry. Sorry to sound so negative, but this is my sincere belief and perspective on the issue (having worked briefly in the industry.)

Next time I go to the doctor and he/she refers me for screenings or treatments not covered because of the newer technology or newer medication, I plan on asking if Bloodletting with Leaches is still covered. I did inform my doctor that I would NOT be paying for imaging that is part of preventative health and screenings.

Good luck

MelissaDallas

It's the same thing as "free" screening colonoscopies. If they remove a polyp your "free" colonoscopy just cost you thousands of dollars out of pocket if you have a high deductible.

StrongEnough13

I'm having the same issue with my annual mammogram not being covered by my insurance and being billed to me due to large deductible. I was outraged to find that since I have had BC and a lumpectomy, I will forever now need diagnostic mammograms rather than screening mammograms and that only screening mammograms are covered as preventive care by my insurance (Aetna). It's nonsensical that a person with higher risk cannot get required testing paid for as preventive care. I can't believe this is legal. When I get the energy, I plan to appeal. Hopefully I haven't missed my window. I agree that we need lobbyists to close this loophole. I was told by my BS that since I have had BC and surgery, the insurance must now cover anything I want to do with my breasts to make them "right" again, implants, reduction, reconstruction, whatever. So why do they not have to cover annual diagnostic testing? There should be something in the Women's Health and Cancer Rights Act to address this, but apparently, there is nothing.

chi-girl

Just following up in case it helps someone. It took me *over* a year, but I finally got the bills covered by my insurance. Someone at the insurance company finally took pity on me and told me what "codes" had to go on the submittal to the insurance company in order for them to cover it. Then I had to fight with the hospital to get it re-billed. I eventually got it resubmitted with the correct codes and was told it was now slightly over a year and the insurance wasn't going to pay. I ended up documenting it all and submitting an appeal to my insurance company. I also posted on their Facebook page for good measure. (They were very responsive on that--I have UHC.)

The appeal worked and they paid. Especially since enough time had passed and they had covered my 2015 mammogram (exact same thing.) I think that made it hard to argue why 2014 wouldn't be covered.

I now go into my mammagram appointment with the codes in hand and say...these codes HAVE to go on here.

indomitable

I have fought with my insurance company every year, sometimes winning and sometimes losing, about charges for my yearly mammogram, and know from discussions with other women that this a common 'rabbit hole' - going for a yearly screening and being told, after the fact, that the mammogram was instead coded as diagnositc. So, chi-girl, which are the codes that worked to have yours properly coded as screening? As the codes are universal, your sharing will allow others to know what to expect.

tuma

I work in billing/coding and upset with this issue as well. I feel it is so unfair for patients, but changing the code is not easy. It is wrong to fix the code just to get the exam covered if there is no documentation to support it. It is considered a fraud. If the doctor says it is a diagnostic/follow up exam, we can't code/bill otherwise. If it is an annual screening/preventative exam, the doctor has to order it as a screening exam and it must be documented as a screening exam.

Tattoo45

I am currently going through the same problem:

Had my very first mammogram recommended by my Dr as I am 45 years old . They coded under diagnostic instead of screening as I had a lump but never told me there was a difference for the insurance. I am now stuck with a $460 bill that shouldn't be as no one ever told me what I was going to have done I never even saw the Oder for the exam the drs nurse send it for me and took the appointment.

I had called my insurance before the exam and they said it was 100% covered as I was aloud one mammogram per years.

I am not paying!!!

Moderators

Tattoo45-

That is so frustrating! Is there anyway you can reach out to the billing department at the center you were seen, and ask that they resubmit the claim to your insurance with the correct code?

The Mods

mimi70

I had to back for a diagnostic mammogram and sonogram twice within a few years. Both times were due to an area of dense tissue in the same place. My gyn told me that if I continued to go to the same imaging center, they would have record of the previous results and most likely I would not have to go through the diagnostic again. Not true. They saw the same place and again wanted me to go through a diagnostic and a sonogram. Each time they do this I pay upfront for the diagnostic mammogram around $160, get another bill from the hospital for $215 for the sonogram and yet a third bill from the radiologist for $200. Seems like a racket.

J-hill_89

what code did you use to get coverage

edwards750

Appeal it. We have BC/BS and were charged OON for a procedure. Long story short we had supporting documentation so we won the appeal. I have to have diagnostic mammograms because of a family history. We’ve never had a problem with them paying for it. I have also had a GP recode a procedure. It was for a stress test. It was miscoded to begin with.
Good luck!

Diane

Trixie619

I just had my first time mammogram done after turning 40. In a nutshell, I obtained a script from my gyno and it was for a screening mammogram which specifically provides the medical coding as “77067” and is covered as preventative care under my insurance. Provider then billed for a diagnostic mammo based on a script they wrote behind my back and had my gyno sign which I knew nothing about until after the fact. My script was dated Jan. 2, 2019 (the same day as my mammogram) and the providers script was dated Dec. 24, 2018 which was on or about the date I made my appointment for the mammogram. The only person I spoke with at the providers office prior to having my mammogram done was a “scheduler” to make my appt. So, a schedulers script, (who is not a healthcare professional) overrides and makes my script from my gyno obsolete even though my gyno personally seen me in their office, examined me and made an order for a screening mammogram. Still battling with insurance through appeals and will be taking the provider to small claims court if nothing can be resolved. I’m not giving up. This is wrong and I don’t know how many women the provider is doing this to