Summary: Women and their insurance companies are paying wildly varying prices for mammograms, and doctors and clinics are charging wildly varying prices, we found in our crowdsourcing project with the Brian Lehrer show on WNYC. Read on to learn more and hear some horror stories, or…
We asked people to send in prices of routine mammograms for our project with WNYC. People told us what they were charged, what they paid and what their insurers paid. We knew that there would be some variation in what people considered a routine mammogram, and some variation in the price — but we never expected the range to run from $0 to $2,786.95!
First things first: thanks to the nearly 400 of you who shared your bills. We went on the air with Brian Lehrer at WNYC public radio here in New York to talk about health prices, and asked you to send in your information. When you did, we learned a lot, and we are honored that you joined in with us.
How much does a mammogram cost?
Here at clearhealthcosts.com, we do pricing surveys for the self-pay prices for common procedures. What we have found here in the New York area is a range from $50 to over $600 for a mammogram if you ask in advance and pay cash; here’s our price list for New York and here’s one for the Los Angeles area.
Your data from WNYC shows a fairly substantial number of payments by insurers around the Medicare rate for a screening mammogram, which is around $170. There is a substantial number of charges by providers, and payments by individuals paying cash, around $350-$550.
Check below for tips on finding a cash or self-pay price.
Different Prices At The Same Provider
You told us crazy things like this:
You told us you had heard $180 and $540 from the same provider.
After a charge of $1,195.90 and a payment of $1,195.90 at a big New York teaching hospital, one of you wrote: “Insurance paid in full, employer pays 100% of routine mammograms. Received separate bill from radiology for $175, plan discount $123.02, plan paid $51.98.”
At the same hospital, a bill of $1,105.42 and a payment of $884.34, with this comment: ”The cost of a mammogram has increased enormously in the past 2 years. From the same facility in 2010 it was $175. It took almost a year for [insurer] to pay. In the meantime [provider] turned the billed over to a collection agency so I paid the 884.34. I have not as yet been reimbursed though I have tried, with calls to [provider] customer service and letters to them.”
At another big New York teaching hospital, you told us charged prices ranged from $505 to $719 (one higher charge, $972, was identified as a diagnostic mammogram). The payments from insurers ranged from $129.35 to $698.
Delayed and Confused Bills
A comment: “I went for a mammogram in Feb as that was the final month of my insurance with this particular carrier. They paid for my mammogram, according to the statement I received, $21, (which I was shocked at). Months later the hospital started billing me $719 and when I inquired why, they said my insurance company claimed I was only enrolled through Jan and they retracted the payment. I’m still fighting this but when I called the hospital and said, ‘Look I know the insurance only paid you $21, let’s negotiate a deal so that I don’t have to waste time fighting this’. The reply, ‘Ok, we’ll give you 10% off”. Me ‘Uh, No.’ ”
A lot of people find bills impenetrable.
“I had to call hospital billing just now to get the price of the routine mammogram, because on my bill it was lumped together with the cost of other procedures I had done that day. I was also told there is no price list of procedures per se (even for routine mammogram).”
Fees and Figures: Negotiation Works
A number of people are negotiating prices with providers, asking for a cash or self-pay rate. Negotiation of this nature is possible in advance, but harder after the procedure is done.
One person wrote: “I haven’t actually had the mammogram yet, but since I can’t afford the insurance premiums (over $1100 a month, individual plan, 3rd worst plan) I asked what it would cost me for a mammogram. The answer — $180 if I could pay it all that day, $540 if I wanted a payment plan. The amount of $180 appeared to be what they would collect from the insurance company if one was involved. This was for a digital mammo.”
Another wrote: “I have a very high deductible policy. I always say I don’t have insurance as I never meet the deductible. This facility has new digital equipment. I pay $100 for the mammogram and a similar amount for the radiologist to read it. I have done this for the past 10 years. I am lucky enough to be very healthy but I have had an occasional expense. All have been out of pocket, paid by credit card and are far less than I would have paid using an insurance policy. I view insurance as catastrophic coverage only. Truly much cheaper for the individual. … If we all took an interest in the total charges, fees would fall.”
Wait, aren’t mammograms supposed to be free under the Affordable Care Act? Yes, and the law is coming into effect. But (sigh) it’s complicated, so we did a completely separate blog post about that. You can find it here.
Total Price Chaos
Here are a few of the things you told us:
- There’s a great deal of confusion about what’s routine and what should be covered by insurance. Some of this seems completely innocent and accidental, but some seems to be annoying, costly for the woman involved and downright upsetting. Is there a charge for reading a mammogram? Is a mammogram of any value without a reading? Is there a charge for receiving a mammogram from a provider? Can it possibly be right that a mammogram is not read fully on the first pass, so the woman needs to come back for a second one, that second one no longer covered by insurance?
- Hospitals generally charge more than self-standing radiology practices.
- The figures we received often were clearly a routine screening mammogram, but just as often they were something different — a diagnostic mammogram, for someone who has signs of cancer, or a family history, or something similar, and therefore the mammogram is no longer a routine screening but a search for cancer. Because the routine, screening one is generally less expensive and less comprehensive than the diagnostic one, the price results are a bit apples to oranges to kiwis to bananas.
- Even knowing those differences, the prices varied widely. Further, the price that’s charged is often completely disassociated from what’s paid. In general, insurers reimburse a fraction of the charged price.
- People are upset about their health-care bills and looking for some clarity.
If you project this mess over the entire health-care marketplace, you start to see what a well-known academic called “chaos behind a veil of secrecy.”
At clearhealthcosts.com, we are a partner to the Brian Lehrer show and thus we don’t have access to your email addresses under the WNYC terms of service. But we wanted a second opinion on what we were seeing, so we showed a limited data set to several people, including Dave deBronkart, a cancer patient and advocate for transformation of the health-care marketplace. He said he was blown away.
DeBronkart added in an email:
“So pleased to see a number of people defining what they want and what they’ll put up with. Imagine what they’ll achieve when they have good information!
“Ultimate takeaway: Consumers evidently do use the info they have, within the constraints we put on them.
“Recommendation: it should be REQUIRED that every provider have a posted price list. Required. And every explanation of benefits should be required to list the medical code for every charge.”
A Bit About Our Ethics and Methodologies
We talked a lot about whether or not we should name health providers. We decided to give props to providers by name if they were nonprofits, especially if they are clearly a resource that women should know about (see our collection of “useful links“).
What we list on the clearhealthcosts.com web site — our surveys of cash or self-pay prices in cities in the New York area and California, and, soon, Texas — have names, address and phone numbers of providers attached to them, so people can go directly to a provider knowing what that provider charges for a cash or self-pay person.
But with the WNYC survey data, we felt that naming a provider or payer for what looked like bad behavior was not part of our mission. (Our lawyers agreed.) How could we know if a provider didn’t read her exam properly the first time? We are not medical professionals.
We are really annoyed at the place that imposed a $50 charge for receiving a mammogram — and the hospitals that sent bills to collection when they were under discussion, or failed to explain what they were billing for. But we won’t name them.
We know enough about the system to know that there’s no one guilty party: incentives are misaligned, and so all the players are at odds. Providers say they have to charge inflated prices to win payments they can stomach. Payers say providers always inflate prices in an unjustified fashion. Government says it’s not able set prices or to regulate all transactions between for-profit entities that are doing business with each other. Drug companies say they don’t get enough money to cover research and development, and at the same time, they seek to put as many people as possible on their drug instead of a competitor’s. Device makers do pretty much the same thing as drug companies.
Health care is a $2.7 trillion annual industry, and it eats up about 18 percent of our GDP. And yet the industry is opaque: no one knows what things cost in health care, because the price that’s charged by the provider is often not what’s paid. Providers tend to charge a high “notional” price, and payers (insurance companies, or the government) tend to pay a lower rate. Payers have a price that’s fixed by law (Medicare, Medicaid) or by contract (private insurers).
So who pays the high sticker price? Uninsured and uninformed citizens.
There’s a growing interest in health-care prices. Health insurance is expensive and a lot of people are uninsured, or out of network or out of pocket for other reasons. (We heard a lot from people who swear by their provider and are certain they want to pay extra for what they regard as better quality testing.)
Rather than point fingers by naming providers and accusing them of misbehaving, we are going to say: It’s time for transparency. The system is broken.
A Few Final Notes
We needed to make a better form, to clarify what’s routine screening and what’s diagnostic. We learned a lot about how to do that, and next time we’ll do better. And yes, we’re doing more of this. Count on it.
The cost of a mammogram (what it costs to provide it); the price (what’s charged); and the payment from the insurer or the government are not related in any consistent way that we could divine.
The figures we received often were clearly a routine screening mammogram, but just as often they were something different — a diagnostic mammogram, for someone who has signs of cancer, or a family history, or something similar, and therefore the mammogram is no longer a routine screening but a search for cancer. Because the routine, screening one is generally less expensive and less comprehensive than the diagnostic one, the price results are a bit apples to oranges to kiwis to bananas. But even knowing those differences, the prices varied widely. Further, the price that’s charged is often completely disassociated from what’s paid. In general, insurers reimburse a fraction of the charged price.
Because this went through our partner WNYC and their terms of service do not allow them to pass on emails, we can’t thank you, our contributors, directly any way other than here and on WNYC. So, thank you again. You are awesome.
Tips on Finding a Cash or Self-Pay Price
- We ask providers: “What is your cash or self-pay rate for a screening mammogram, HCPCS code 77057 ? That would be the rate if I am paying in advance, cash.”
- They tend to have a number, and the numbers are all over the map. In NYC alone, we found people charging as little as $50 and as much as $1,100 and even more.
- We recommend that you use our search box at the top of our home page to find out what Medicare pays for that procedure in your area. Here’s a link to the Kansas City results: In Kansas City, the $11 is for a processing fee that seems to sometimes be charged and sometimes not, and $79 for the actual procedure. Then you could use that info to survey providers yourself.
- Ask “Does that include a reading fee? Are there any other charges?”
- As you are calling, keep notes: names and phone numbers of people you’re talking to.
- When you settle on a provider, call back, and ask for the price in writing, or ask for a receipt upon payment stating that you are paid in full for this procedure.
- Always choose accredited providers; in the case of mammograms, the American College of Radiology accredits providers. Here’s a page where you can find providers in your area.
Response Data–Notes for graphic
In the survey of mammogram costs, you gave us 325 substantive responses. (Some responses did not have numbers but many of those were valuable as well, like the several responses directing us to free mammogram providers.) Some were exact duplicates, probably due to saving twice, so we removed the duplicates. There were two responses that clearly stated that the price was for both mammogram and ultrasound exam/sonogram, so we took them out for this analysis. In some cases, amount charged and negotiated price were in the comment section only, so we transferred those numbers to the correct fields. We then for this analysis looked at only responses that have a non-zero amount both for “Price” (the amount the provider charged/asked for) and “Payment” (the amount the provider was paid by the insurance, the customer, or both). This left us with 214 responses.
To show the information, we sorted the responses by price and for each report plotted both the price (blue dot) and the payment (red dot). You can see from the blue dots that the price ranges from about $100 to over $2,200, with most prices being $800 or less. You can see that payment (red dot) usually is quite a bit lower than price, although in some cases the are the same (red dot on the blue line). It looks like many payments are between $100-200 and most were below $600.
In the inset graph, we grouped Price and Payment separately into $100 ranges, $0-100, $100-$200, etc showing the distribution of the reports for Price (blue columns) and Payment (red columns). The middle of the range is shown on the bottom axis, for instance $250 for the $200-$300 range. You can again see that most prices were below $800. Many payments were at the Medicare reimbursement rate of $100-$200 and most payments were $600 or less.
This is not a scientific study of prices, just reports from interested persons. The questionnaire was quite complicated, to say nothing of the insurance forms, so there are likely some reporting errors. We also believe that several reports were for tests and services more complicated than a screening mammogram, which may explain some of the high price and payment points. Still, mammogram prices are very variable and most mammograms are paid for at a rate far below the listed price. It’s worth your time to ask about the price and to negotiate, especially when you pay yourself or go out of network!
This is Part Two of our WNYC “price of a mammogram” series. The series is outlined here.
2. The overview: How much does a mammogram cost? Prices, payments vary widely, our survey with WNYC finds.
3. We don’t offer medical advice, but we wanted to tell you about the guidelines. When is a mammogram not a mammogram?
4. How much does a mammogram cost? Your tales of bills: $0 to $2,786.95.
5. Women’s health resources. No one should ever have to go without a mammogram or other women’s health issues. Reproductive health belongs to us. Here are some resources, and some thoughts about women’s health.
6. Acts of healing, and of overcharging: Contributors talk about their mammograms.
7. How much does a mammogram cost? The takeaway.
8. How should you choose a mammogram facility? Dr. Geraldine McGinty explains.