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Linda
Brandwin, R.N.
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Linda
Brandwin
is a registered nurse and a medical billing
and claims specialist. For the past 10 years
she has worked directly with insurance companies
to give advice and guidance to the health care
consumer.
Readers may send email
or write Linda Brandwin at 5500 Single Oak Hill
Ct., Woodbridge, VA 22192.
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Insurance
companies usually only cover standard procedures
Jan. 7, 2005
Q:
I
just had my annual mammograms which my insurance company
covers. This year when I went to the radiology office
they told me that for $25 I could have a more comprehensive
and enhanced screening which will be better. They said
the insurance company will not pay for it, so the $25
has to come out of my pocket. Of course, I paid for
it. Why doesn't the insurance company pay for this additional
procedure since this is a better screening for cancer?
A:
A
normal yearly screening mammogram usually consists of
two views of the breast. This is standard; this is what
your doctor recommends for your annual mammograms and
this is what your insurance company will cover. A radiologist
reads and interprets the film.
Your
enhanced and more comprehensive mammogram may be what
is referred to as a diagnostic mammogram. At least three
views of the breast are taken instead of the standard
two. If there is a medical concern, your doctor will
order a diagnostic mammogram which will be covered by
your insurance company. Coverage for this is not determined
by the calendar year but by medical necessity.
Insurance
companies pay for procedures that are ordered by your
healthcare provider. A diagnosis code and procedure
code are required and then the claim is submitted to
your insurance company for payment. A radiology center
can not make a medical determination as to the necessity
of a more comprehensive screening procedure. Only your
healthcare provider can do this. Unless this extra view
of the breast is ordered by a physician, it is not a
covered benefit.
The
enhanced mammogram could also be what is called a computer
aided detection procedure. During the mammogram, information
is put into a specially designed computer program which
is set up to detect certain abnormalities. Therefore,
you not only get a radiologist's interpretation of the
hard copy of your mammogram films, but you also receive
a reading from this computerized program. Some insurance
companies pay for this added procedure, some do not.
You probably will have to sign a wavier stating that
you are aware that your insurance company may not cover
this procedure and, therefore, you will pay for it out
of your pocket. Have the radiology center submit this
claim to your insurance company irregardless. Insurance
companies gather data and evaluate the effectiveness
of new procedures all of the time and so standard coverage
is always changing.
It
would be a good idea to consult with your physician
as to the benefits of a screening mammogram verses a
diagnostic mammogram and a computer aided detection
mammogram. He knows your history and will be able to
make an appropriate recommendation.
As
an addendum to this column, I just received a Medicare
updated bulletin stating that effective April 1, 2003,
Medicare will cover computer-aided detection mammograms
for routine screenings. Hopefully, other insurance carriers
will follow.
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