(Updated 2022) Mammogram costs and insurance companies: We asked what you paid and what your insurance company paid for a routine mammogram.
Sometimes it was straightforward:
“Provider cost, including technician was $175. My insurance company paid $56.95. My cost zero.”
Or this: “So [insurer] paid $112.46 and I paid $25, totaling $137.46.”
But then it started to get complicated:
“Cost was divided into two categories. Mammography for $62.00 and Screening Mammogram for $469.00.”
In this post, part of our series about our crowdsourcing partnership with the Brian Lehrer show at WNYC public radio in New York, we’re examining bills and benefits explanations.
How about this: “Breakdown billed as follows:
“Screening mammogram – $400 Medicare Approved – $ 159.11
“Physician review of mammogram – $ 50.00 Medicare Approve – $ 11.73
“Mammogram to aid diagnosis – $ 325.00 Medicare Approve – $ 152.78”
Or this: “Above I have combined two charges, one $596 for the digital mammogram and one $79 for comp screen mammogram add-on. the above does not include reading the mammogram which was $364 with and adjustment of $174 and a payment of $174. leaving a $15 balance.”
It’s so complicated: Can this bill be right?
People often tell us that our system is so complicated that people can’t tell if their bills or statements are correct. This was a constant theme among the nearly 400 women who told us about their mammogram experiences for our crowdsourcing project with the Brian Lehrer show at WNYC radio in New York. The overview of results are in this blog post; other posts are elsewhere on the blog.
Why should we care? This is a common thing: 37 million mammograms are performed every year in the U.S. If this is so complicated and fraught with confusion, imagine what is going on in the rest of the health-care marketplace.
Here are a few recurring themes. I showed your responses (with no identifying information) to my friend “e-Patient Dave” deBronkart, a patient advocate and a strong supporter of transparency in pricing, and the author of the new book “Let Patients Help,” and asked him to comment.
Problem: I was charged not just for a mammogram, but for many add-ons.
Examples:
“There was an additional charge for comparing this year’s mammogram with a previous one: $50. charge. Medicare paid $11.73.”
“$315 is the total amount. [Clinic provider] charged me $90 for a check-up, and sent me to [radiology provider] for a mammogram, my first. [Radiology provider] charged $190 for the mammogram. [Clinic provider] then charged another $35 to receive the results.”
“prior to getting insurance, I would use the free mobile mammogram vans around Manhattan, and feel a little ashamed for using it even though I had a well-paying job. But I was not able to comfortably afford all
my expenses…. With my new job, I assumed [insurer] would take care of everything. I was shocked when I got the bill. Not only was there the amount above (1211.18, with all said and done, a copay of $144.60…) but an additional, separate amount from the reading doctor himself. Fortunately he was in network, but not until I’d received his first bill labeling him out of network for $175…. This year I returned to the van, with much less shame.”
Charged: $530+$50. paid: $344.76+$37.31. “I was charged $530. for mammogram and $50.00 for diagnostic. [Insurer] paid $344.76 of the $530. and $37.31 of the $50.00. [Insurer] has charged me for the remainder of $197.93. So, [provider] can pick an amount to charge, [insurer] can decide what they will pay, and without recourse the rest gets kicked to me! I am outraged and I’m fighting the bill. ‘
Comment from ePatient Dave: “You gotta wonder — how many people are preapproved to stick their hands in your wallet?? And who approved it??”
Problem: The numbers don’t add up.
Examples:
Billed: $689; negotiated rate/plan discount $691.58. “I don’t understand why the amount billed is less than the amount under plan discounts. The claim detail form is very confusing, but I am very fortunate to have all but $49.98 covered.”
The bill:
ICD9:V76.12 CPT4: G0202 : $402.18, only $285.55 eligible
ICD9:V76.12 CPT4: 77052 : $160.53, only $15.00 eligible
“My insurance statement says that my patient responsibility is zero, but I have received a bill for $140 from the radiologist. I cannot tell how they derive this figure, since the difference between what was billed and what was paid is $163.18. My mammograms used to be entirely covered by any insurance I have had. This truly sucks, especially since I pay over $600/mo. for my policy with [insurer]. Each year I wonder if I would be better off being uninsured.
“Thank you for doing this research”
Comment from ePatient Dave: “This is what you get when the bottom line answers to no one: nobody feels any responsibility to even know what’s going on!”
Problem: This bill or explanation of benefits is incomprehensible.
Examples:
“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).”
Charged: 917.90, paid $428.12. “This procedure was billed twice on the same date, with each one seeming to be paid at the rage of $428.12. Note on the record said it was paid at the agreed or contracted rate.”
“I seem to have 2 different EoBs one for $629…Medicare paid $137.12. A different EoB for same date and procedure shows charge of $105, and Medicare paid $41.97. I do not know which EoB is the correct one…too confusing.”
Charged: 1,105.42, paid 939.61 “Great idea, folks! PS I had an additional bill associated with this service (same day, same doctor’s name on a separate insurance Explanation of Benefits), and I don’t know why. It was for $175 charged by (provider), “discounted amount” of $123.02, and “allowed amount”/”amount paid” $51.98.” “
Comment from ePatient Dave: “More hiding the acorn! And… no price list? Really?
“And I don’t see why they’re allowed to call it an Explanation of Benefits — the FTC should bar them from calling it an ‘explanation’ if nobody can tell what it says!”
Problem: I had to pay extra for a second test. (Or, after that happened to me, I fired my radiologist.)
Examples:
“Paid the insurance co-payment for the first mammogram scan ($25 I think). I was later notified by the provider that one breast image was not clear and that I needed to schedule another mammogram along with an ultra-sound. I scheduled the re-exam, they took another mammogram of the breast and told me everything was ok, and that we didn’t even need to do the ultra-sound test. My insurance company made me pay $244 for the re-test because it was no longer categorized as my “Annual” exam. I eventually changed insurance companies as a result.”
“I paid $0 for the mammogram. It had to be repeated a week later, and the radiologist charged $170 to read the second one. I paid $22 for that.”
“I go to this provider because she looks at the films while patients are still in the office. If there are questions, the films are redone and reread before one leaves the office. This eliminates the terror produced by finding out there are questions and having to live with the terror waiting for a new appt to find out if you have breast cancer. “
Comment from ePatient Dave: “So: the provider goes through the motions, it doesn’t work (an unusable mammogram), and they don’t refund the money. Sweet! Imagine a restaurant where they burn your dinner and make you buy another one!”
Problem: The charges and the payments seem to be disconnected from each other. (And I’m going back to Texas or Kansas to have my mammogram.)
Examples:
“Actually, the provider keeps making mistakes on their initial submission to my health insurance provider [Insurer] and the EOBs always show $0.00 as approved and/or paid. I have no follow-up EOBs showing the amount paid to [provider]. Sorry.”
“I was given a quote of $1200 minimum for a mammogram at [first provider]. [Second provider] would not even put me on the schedule if I was paying out of pocket (“only Medicaid and Medicare). So for less half the price of a mammogram at [first provider], I bought a plane ticket to Kansas, rented a car, and had my mammogram on the same brand-new equipment they use at [first provider]. Ridiculous.”
“My employer-provided insurance ([insurer]) did not cover a penny of this, because I used an out-of-network provider. I am covered by a PPO Plan, and many, many other procedures are covered at 70% if you go out of network. But if you choose to get a routine mammogram out-of-network, zero. This came as a very unpleasant surprise!”
“When I had a mammogram in Texas at Solaris, I didn’t pay a thing. My insurance covered it all. What a shock moving to Connecticut where I was charged $260.24 in addition to what my insurance paid, plus I had to pay the radiologist $73.91 additionally. In the future I’ll fly back to Texas to have my mammograms. It’s cheaper for me!”
Comment from ePatient Dave: “Not saying what they did for you is exactly the same as if a waiter brought you a non-itemized check.
“Tip for empowered consumers: if someone tells you the bill or explanation has an error in it, ask what’s being done to figure out how it happened. And if you get stonewalled, DEMAND to know.”
Problem + Solution: I pay more to go out of network.
Examples:
“I choose to go out-of-network for my mammogram because I believe I receive a higher level of care. At [provider], the same radiologist examines me every year and reads my films while I wait. For the past two years, I’ve also had breast sonograms at the same facility due to dense breast tissue, and they cost an additional $400.00. The same applies to my GYN: I go out of network and it’s expensive for bi-annual visits, but I negotiated a 20% discount so I pay $560 each visit instead of $700. Again, it’s worth it to me to have vaginal ultrasounds at each visit and a top GYN who cares about menopausal women.”
“In 2004, they picked up a tiny tumor. I was given a core breast biopsy, which was benign. … Incidentally, 20 years ago, 2 friends told me that they’d been to other radiologists who did not pick up their breast problems. Ultimately, their gynos then recommended [provider], who found one benign & one malignant tumor at an early stage. …they may be expensive, but my experience tells me that their expertise is worth the price. … Additionally, many radiologists take the mammo, read it days later & patient may have to return for a follow-up. [provider] read the mammo immediately &, if necessary, additional views or ultrasounds are taken minutes later.”
Comment from ePatient Dave: “That closing line is the sound of an awakened, empowered, ‘don’t feed ME this’ consumer. That’s what it looks like when you see one.
“Yes, there are important differences between doctors. We need to demand the ability to find out, and to move to another doctor. Otherwise the system is insisting on payment while not insisting on professional competence. That’s what we had in other industries before consumer protection laws came along — right?”
Mammogram prices
First, screening (preventive) mammograms for women over 40 should be covered by your insurance if you have a plan that is compliant with the Affordable Care Act – which guarantees coverage for preventive health care in several major categories. That’s a mammogram every 2 years for women 50 and over, and as recommended by a provider for women 40 to 49, or women at higher risk for breast cancer.
For people whose mammograms are covered by insurance, there may be no need to know the price. But millions of mammograms are performed in the United States every year, and millions of people are not covered by insurance. Also you might choose to pay cash – or you might be responsible for a percentage of the cost, depending on your insurance.
Here are prices for a screening mammogram in the New York area, ranging from $60 to $421. Here are prices for a screening mammogram in the San Francisco area, ranging from $150 to $470.
Here are prices for a screening mammogram in the Philadelphia area, ranging from $60 to $421. Here are prices for a screening mammogram in the Dallas-Fort Worth area, ranging from $139 to $508.
The prices for a mammogram can vary widely, for this and other procedures. Educate yourself.
This is Part Four 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.
* * * * * * *
Caption for graphic: Credit Frederik Lindberg
In the survey of mammogram costs, you gave us 395 responses. (We did a version of this graphic with that data for our first-day graphic here; this is an updated version with the nearly 395 final tally, while the first one had the 325 entries that had been shared up to a few days before we released results.) 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 to ask about the price and to negotiate, especially when you pay yourself or go out of network!
