In the world of complex healthcare costs and calculating your out-of-pocket expense, getting a mammogram may be the most confusing. It all depends upon whether your mammogram is considered a “screening” procedure or a “diagnostic” procedure.
I’m a physician and this makes no sense to me. Screening procedures are done to make a diagnosis in most cases. You don’t do a colonoscopy just to find out if you need a colonoscopy! But it seems that analogy may not work for mammograms.
Here’s what I’m talking about: Let’s say you’re a woman of 50 years and you get a routine mammogram. The scan shows something suspicious so your doctor tells you to get another mammogram “to be on the safe side.” After you get the second scan you find a bill in your mail for $350 – one you didn’t get for the first mammogram! About now you’re thinking, “There has to be a mistake. If I didn’t have to pay for the first one, why am I getting a bill for the second one?”
Leslie Albrecht, writing for MarketWatch.com says this is a very real scenario happening to many women. She says blame it on the Affordable Care Act.
In 2010, the Affordable Care Act (ObamaCare) was passed by the Democratic-controlled Congress without a single Republican vote. I’ve been fascinated with this historic piece of legislation that is misnamed, like most bills in Congress. (I’ve written two books on the subject.) The ACA certainly did not make healthcare more affordable for most people – in fact, it made it more expensive. The main reason for this increased expense is that the bill forced insurance companies to provide coverage for all sorts of procedures whether you needed this coverage or not. Insurance companies were not allowed to write policies that didn’t provide so-called essential health benefits.
That meant all policies provided coverage for routine screening exams such as mammograms, regardless of whether or not you were a woman! But only for the “screening exams” – not the “diagnostic exams.” That means your diagnostic exam is not covered and thus you get the $350 bill. What’s the difference in the two exams? Molly Guthrie, the vice-president of policy and advocacy at Susan G. Komen, a non-profit that raises awareness and money for breast-cancer research, has answers. She says health insurers can, and do, make patients pay out-of-pocket costs for follow-up “diagnostic” mammograms, even though the machines and procedures are exactly the same.
“When the ACA was passed, it was hammered into everyone’s head that all screening was free of charge,” Guthrie told MarketWatch. “So, it’s really confusing when patients get the screening done that they’re told that they need, and they have to pay up front or they get surprised by a bill after the procedure is done.”
Who gets screening mammograms v. who gets diagnostic mammograms?
Screening mammograms are the ones done typically on women every two years if they’re “average risk” for breast cancer and have no strong family history. Women have traditionally started these at age 50, but new draft guidelines suggest it should be age 40. Between 12% and 20% of people who get a screening mammogram are then told they need a follow-up “diagnostic scan,” according to Guthrie.
The “diagnostic scan” can seem like it’s the same procedure, but insurers don’t treat them the same. Billing codes change when the name changes. Diagnostic mammograms are also recommended for a host of other reasons, including for women who have so-called “dense breasts”, which is about half of all women, according to the American Cancer Society. Anyone with a family history of breast cancer, people with certain genetic conditions, and anyone who’s gone through breast-cancer treatment are also told to get diagnostic mammograms.
Some states are addressing this financial conundrum and it’s a rare instance where both red and blue states are on the same page. Texas, New York, Oklahoma, Washington state, Maryland and Tennessee are among those that have passed laws eliminating out-of-pocket costs for diagnostic imaging. However, these laws only apply to people in state-regulated health plans, which are used mostly by smaller employers or state employees. Federal legislation to address the issue was introduced in 2021 with bipartisan support, but didn’t move forward. A Komen spokesperson says it is due to be reintroduced soon.
