Billing for mammogram depends on screening or diagnostic examination

Ask Lance


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Dear Lance,

I have Original Medicare. I recently had a mammogram and was billed by the radiologist for 20 percent Part B coinsurance. A friend told me that when she had her mammogram there was no amount due to the radiology facility. I don’t understand why she paid nothing and I got a bill. Can you explain the difference?

Confused

Dear Confused,

I can certainly understand your confusion and will try to explain what I think are the differences in these two situations.

First, please look carefully at what you received from the radiologist to be certain that you are actually being asked to pay or whether it is just a statement for the service you received that is being billed to Medicare. If it is a bill you are being asked to pay, we must look for the reason.

Medicare covers a substantial number of preventive or screening services to keep you healthy. Many of them are provided at no cost and do not require that the Medicare Part B deductible ($183 in 2017 and 2018) be met. Among these many preventive services is breast cancer screening (mammograms).

Medicare covers screening mammograms once every 12 months for all women who are 40 and older. You pay nothing for this preventive service if provided by a qualified healthcare provider who accepts Medicare assignment. The Part B deductible does not apply. I believe that this explains why your friend was not billed for the 20 percent Part B coinsurance.

An entirely different situation occurs if (1) you have a history of breast cancer, (2) during a manual breast exam your doctor feels a lump or sees another abnormality, or (3) the radiologist is reading your mammogram and sees something suspicious and does additional radiology studies. In this case, the mammogram is not a screening examination but is a diagnostic one to determine the nature or severity of a particular abnormality.

When it is necessary that a diagnostic mammogram be done, a 20 percent co-insurance applies as does the Part B deductible. I suspect that this situation applies to you and is the reason that you received a bill from the radiologist.

You might wish to discuss with your doctor whether they ordered a screening or a diagnostic mammogram. If they ordered a screening exam but a diagnostic one was done, have them ask the radiologist the reason.

Many Medicare beneficiaries are unaware of the wide range of preventive services available to them. I strongly recommend the following Medicare website to learn of these services: medicare.gov/Pubs/pdf/10110.pdf.

Publication 10110, “Your Guide to Medicare’s Preventive Services,” also can be ordered at no cost from the Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244-1850.

The amount you pay for preventive services varies on whether you have Original Medicare or a Medicare Advantage Plan (like an HMO or PPO). If you get your health care coverage through a Medicare Advantage Plan, call your plan for more information. 

To contact a SHINE volunteer counselor for confidential and unbiased assistance, call the Elder Helpline toll-free at 1-800-963-5337 or call 321-752-8080 locally. SHINE has 12 counseling locations throughout Brevard County. Counselors can assist you by telephone or in person. To find a SHINE counseling site near you, go to floridaSHINE.org or call the telephone numbers listed above.