Insurance Question

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Jenniferz
Jenniferz Member Posts: 541
edited June 2014 in Life After Breast Cancer
Insurance Question
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  • Jenniferz
    Jenniferz Member Posts: 541
    edited July 2009

    I didn't quite where to post this, but this is something I've been battling with our insurance, billing, doctor group for a while now.

    In March, I went in for my mammo as scheduled.  My insurance is through Aetna.  My benefits clearly state that I am to get one "free" mammo a year. (Free in that Aetna pays for it.)  Well, here's the rub.  Because of the bc diagnosis, I can't seem to get the insurance to pay for the mammo.  THEY say it is because it is coded wrong.....the billing says that no, it's coded correctly and it's your dr.'s fault, and my doctor has tried to change the order twice to run the claim through again.  If it is run through as a screening mammogram, it's paid for.  If it's run through as diagnostic, it covers 80%. What I had in March wasn't diagnostic....it was the screening....and according to it, it was clear.  (horrah for small favors!)

    I will be going to my doctor tomorrow for just tumor markers, and won't see her, but will see her nurse/secretary.  How can I make these people understand that for Aetna to pay, they have to run it through as screening.  Is it customary for us "una-boobs" to have a diagnostic mammo rather than a screening one?

    Anyone else having this problem?

    Jennifer

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  • otter
    otter Member Posts: 6,099
    edited July 2009

    Jennifer, my breast surgeon wrote the orders for my first post-mastectomy mammogram on my remaining breast as a "diagnostic mammogram."  She scheduled it just 6 months after my surgery, which (apparently) is earlier than the standard scheduling after a mastectomy without recon.  Even so, my insurance paid for it.

    Now, a year after that, I am scheduled to have another "diagnostic mammogram" on my remaining breast at the same breast health center. 

    I don't know for sure why my surgeon wrote the orders that way, instead of for a screening mammogram.  In my case, the tissue in my remaining breast is very dense; and the radiologist told me last year that a new tumor is not likely to be seen in there by mammography.  (My original tumor in the other breast was never seen on a mammogram.)  My surgeon knows that, so she might be requesting diagnostic mammograms (3 views, with immediate interpretation) instead of screening mammograms (2 views) just to be more cautious.

    I guess I never imagined that my insurance (a large group BC/BS plan) might not cover a "diagnostic" mammo when it would cover a "screening" mammo.  I am being treated at a breast health center that's affiliated with a comprehensive cancer center at a major university hospital.  My surgeon has decades of experience with BC patients, and she is very familiar with my insurance plan.  So, I assume she knows what she's doing.

    Good luck in your battle!

    otter 

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  • Jenniferz
    Jenniferz Member Posts: 541
    edited July 2009

    And she probably does, Otter. I did finally get ahold of someone in the billing department, and she told me that she was going to pull my record and see if she can change the code.  Said that she was familiar with this problem, and was going to "flag" my charts.  I guess maybe when the radiologist sees only one film come through, maybe he thinks it is a diagnostic one.  Who knows.  Anyway, she said she can fix it, so we'll see.

    Thanks for your post!!

    Jennifer

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