Diagnostic mammogram vs. screening: One could lead to a surprise $350 bill

Let’s say you’re a 50ish woman and you get a routine mammogram, patting yourself on the back for being proactive about your health. The scan shows something suspicious that the doctors want to get a closer look at, so your doctor tells you to get another mammogram to be on the safe side. You do this, and a few weeks later, you get hit with a $350 bill. You may think, “Wait a minute, why am I being charged? Aren’t mammograms covered by insurance?” 

Welcome to the club. You’re getting a crash course in the financial minefield of breast health. Here’s what’s going on.

Thanks to the 2010 Affordable Care Act, patients aren’t charged for preventive “screening” mammograms. But 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, said Molly Guthrie, the vice president of policy and advocacy at Susan G. Komen, a nonprofit that raises awareness and money for breast-cancer research. Patients are also charged out-of-pocket costs for diagnostic breast imaging that doctors often order after an initial screening mammogram, including ultrasounds, MRIs and 3D mammograms.

“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 vs. who gets diagnostic mammograms

Screening mammograms are the ones women typically get every two years if they’re at “average risk” for breast cancer and have no strong family history of the disease. Women have traditionally started getting these at age 50, but new draft guidelines suggest lowering the age to 40. 

Between 12% and 20% of people who have a screening mammogram are then told they need follow-up breast imaging such as a diagnostic mammogram, Guthrie said.

Even though the follow-up mammogram can seem to the patient like it’s part of the same series of tests, insurers don’t treat follow-up mammograms the same as the initial mammogram. This is when the mammogram goes from being labeled screening to diagnostic in billing codes that determine how much a patient pays. And this is when the bills start.

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 who get mammograms, 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 of our most vocal people that are confused and angry about this are those that were fortunate enough to survive their initial diagnosis,” Guthrie said. “In order to make sure their cancer hasn’t come back, they’re forced to pay out of pocket because it’s coded as a diagnostic mammogram instead of a screening mammogram.”

Also see: At what age should I get a mammogram? Breast-cancer screening guidelines are changing.

How much does a diagnostic mammogram cost? 

A diagnostic mammogram cost $349 on average in 2018, according to a Susan G. Komen report that analyzed prices in 10 states. Prices varied widely: One Texas woman with private insurance was charged $836 for a diagnostic mammogram, while an Illinois woman without insurance paid $150, Komen found.

Why are screening mammograms free, while diagnostic mammograms come with out-of-pocket charges like “copays” and “co-insurance” (the insurance industry’s terms for money you owe)? It comes down to how the ACA defined “screening,” Guthrie said. The narrow definition requires insurers to cover preventive screening mammograms at no cost to patients, but they have wiggle room to charge copays or co-insurance for follow-up diagnostic imaging. 

Indeed, after the ACA passed, out-of-pocket costs for diagnostic breast imaging increased steadily in the years that followed, a 2021 study of women with employer-based health insurance found. 

Susan G. Komen’s policy advocates are working with the Biden administration on expanding the ACA’s definition of screening, which would potentially remove patient costs for all breast-cancer screening. 

Why this matters

Mammograms can already be anxiety-inducing, given that their purpose is to detect a potentially fatal disease. Financial stress adds another layer of worry. Far worse, though, is the fact that the expense of diagnostic mammograms and other recommended imaging makes many people avoid getting these tests. 

One recent study published in JAMA Network Open found that women whose insurance charged higher out-of-pocket costs for diagnostic tests underwent “significantly fewer” follow-up diagnostic breast procedures than women in plans with lower out-of-pocket costs. The findings “suggest that out-of-pocket costs continue to be a barrier for early diagnosis of breast cancer despite the removal of cost-sharing from initial breast cancer screening examinations,” the researchers wrote.

“The whole process was frustrating — financially and emotionally,” said one woman interviewed in the Komen report about diagnostic breast imaging. “So much that I questioned whether these tests were doing any good or if the healthcare industry was just trying to nickel and dime me.” 

The Komen report also included firsthand accounts from doctors, including one whose 32-year-old patient found a lump in her breast. She put off diagnostic imaging because she hadn’t met the deductible on her insurance and couldn’t afford the tests. By the time she had a biopsy, the patient had developed metastatic breast cancer, which killed her 18 months later. “I can still picture her mother in the waiting room after her biopsy just crying her eyes out,” the doctor told Komen. “It took me a long time to get over that.”

Skipping diagnostic mammograms can have particularly dire consequences for Black women, who are disproportionately affected by aggressive breast cancers, 40% more likely to die of breast cancer than white women, and face more financial strain from breast cancer than white women.

Good news: Out-of-pocket costs have been eliminated in 13 states

This financial pitfall is being addressed, and it’s a rare instance where 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.

The state laws are a start, but they only apply to people in state-regulated health plans, which are mostly used by smaller employers or state employees. Federal legislation to address the issue at a national level was introduced in 2021 with bipartisan support, but didn’t move forward; it’s due to be reintroduced soon, a Komen spokesperson said.

Insurance companies have opposed these laws, in part because of concern that cutting patients’ out-of-pocket charges would lead to significantly higher costs for insurers, Guthrie said. This hasn’t happened in the states where out-of-pocket costs have been eliminated, according to Komen, which is tracking the results of the state laws. Removing costs for diagnostic imaging would save insurers money in the long run, Guthrie said, because cancers would be caught earlier when they’re less expensive to treat. 

Insurers have also argued that removing out-of-pocket costs could lead women to frivolously request mammograms, Guthrie said. (Your columnist’s take: This sounds like a talking point created by someone who has never had their breast flattened inside a mammogram machine.) “I don’t know any person out there that’s like, ‘I’m going to have a diagnostic mammogram or an MRI or ultrasound done for fun,’” Guthrie said.

The trade group representing health insurers says it wants women to get the screening they need, and pointed to programs that insurers run to help people get preventive screenings.

“Every American deserves access to preventive care and screenings to catch conditions early before they progress,” said David Allen, a spokesperson for America’s Health Insurance Plans. “And health insurance providers are leading the way by encouraging the people they serve to get their recommended preventive services because proactively seeking care and tackling health issues helps people stay healthy and reduces the risk of patients’ conditions advancing and requiring additional care.”

AHIP also notes in its report on preventive screenings that the U.S. Preventive Services Task Force, a national panel of experts that sets cancer-screening guidelines, has warned “that all women undergoing regular screening mammography are at risk of obtaining false-positive results and unnecessary follow-up biopsies, known as ‘overdiagnosis.’ Beginning mammography screening at a younger age and screening more frequently may increase the risk for overdiagnosis and subsequent overtreatment.”

How to avoid a surprise bill for a diagnostic mammogram

First, see if you are in one of the states where out-of-pocket costs have been eliminated for people in state-regulated insurance plans. Second, now that you know the difference between a diagnostic and a screening mammogram, ask your doctor how your mammogram will be coded, and ask your insurance company how much you’ll be charged in out-of-pocket costs such as copays and co-insurance. Some doctors will even work the system for their patients and make sure a mammogram gets coded as screening rather than diagnostic to try to help them save money, Guthrie said.

If you’re having a hard time getting answers from your insurance company, the nonprofit Patient Advocate Foundation has tips for talking to your insurance company and for filing an appeal if you feel you’ve been unfairly denied coverage. PAF also has a directory of financial resources for breast-cancer patients.

The verdict

Usually I declare a “winner” between the financial options in this column, but that doesn’t apply in this case. Both screening mammograms and diagnostic mammograms can save lives, but one can have a significant financial impact.

“We just constantly hear from people that the financial burden of this diagnostic imaging is too much, and that it’s forcing women to delay,” Guthrie said. “Unfortunately, the breast cancer doesn’t just go away. It’s going to continue to grow and it’s going to be harder to treat and more deadly.”

If you have ideas for future Financial Face-off columns, send me an email at lalbrecht@marketwatch.com.