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Screening or diagnostic mammogram? The difference could cost you

Most insurance plans cover screening mammograms in full, but that's not the case for diagnostic mammograms.

Blanca Rubio performs a mammogram on a 65-year-old patient at Evanston Hospital in Evanston, Illinois.
Blanca Rubio performs a mammogram on a 65-year-old patient at Evanston Hospital in Evanston, Illinois.Read moreHeather Charles/Chicago Tribune/MCT

It had been a few years since Deanie Gauntlett's last mammogram, so when the X-ray showed a few unusual spots, her doctor ordered a follow-up diagnostic scan.

The diagnostic test had that same uncomfortable, is-this-over-yet squish, but was different in one discernible way: its price tag.

Though Gauntlett's screening mammogram was covered in full by her health-insurance plan, she owed a $65 co-pay for the diagnostic version.

The scan's fee wasn't a big deal for the 45-year-old Exton mom, who does her best to follow doctor's orders. But when the doctor suggested she come back every six months for diagnostic mammograms to keep an eye on the cysts it showed, she balked.

"Do I really need to do this every six months?" she recalled asking.

Most insurance plans cover screening mammograms in full. They're among the basic, preventive services that the Affordable Care Act mandated its marketplace plans cover without a co-pay or co-insurance, even if the member's deductible hasn't been met yet. Pennsylvania law requires most other insurance plans to do the same.

Diagnostic mammograms, however, are not covered the same way. Patients who have them may owe co-pays at their doctors' offices and receive bills if the scans are subject to their plans' cost-sharing terms and they haven't yet met their plans' deductibles.

The nuance is confusing and can result in unexpected bills.

"They all say, 'Well, I thought mammograms were free,' " said Pat Halpin-Murphy, president of the PA Breast Cancer Coalition, who says confusion about mammogram costs is a common question the patient group receives. "The words screening mammogram and diagnostic mammogram don't have meaning to the average person."

Screening mammograms are X-rays of breast tissue recommended for women to have annually beginning in their 40s.

Diagnostic mammograms use X-ray imaging to show different angles and are ordered if a doctor notices abnormalities on a routine scan.

Most women who go to the doctor for the routine test will have screening mammograms, but not always. Women who have a history of breast cancer or who have breast implants may receive diagnostic mammograms instead of screening mammograms, said Debra Somers Copit, an independent radiologist and former director of breast imaging at Einstein Healthcare Network in Philadelphia.

"There's a gray area," Somers Copit said of the standards for ordering a screening or diagnostic mammogram for some patients.

Even a patient who knows she is having a diagnostic mammogram may not have realized it would be covered any differently than a routine mammogram.

Insurance companies commonly negotiate "allowed rates" for diagnostic mammograms that are lower than the amount the imaging center billed for, but you may be responsible for part of the cost.

Insurers often require members to pay a greater share of the cost for diagnostic scans to combat overuse of such tests and steer patients to preventive services whenever possible, said Beth Virnig, a professor and senior associate dean of academic affairs and research at the University of Minnesota's School of Public Health.

"What it probably means is no one has considered the barriers to actually following up on a screening, and that's this push-me-pull-you that happens in health care," she said. "We have overuse, we're going to curtail it, but something curtailing overuse puts barriers in other parts of the process."

Some plans have separate deductibles for imaging services, meaning you may still owe money, even if you've hit your plan's overall deductible, she said.

Though Gauntlett wasn't too worried about her $65 co-pay this year, she's concerned about how much she'll spend on her diagnostic mammogram next time.

The family has insurance through her husband's employer, and next year the plan will require members to pay a greater share of imaging costs.

The imaging center billed Gauntlett's insurance $459 for her screening mammogram, which the plan negotiated down to $353 and paid in full.

The diagnostic test was more expensive – it was billed at $651, and her plan reduced the rate to $471. Gauntlett owed a $65 co-pay for that scan.

Her doctor had also ordered a breast ultrasound, for which the imaging center charged $4,468. Gauntlett's insurance negotiated a rate of $248 for the scan and paid it in full.

Gauntlett doesn't know exactly how much of that the family's health plan would require her to pay in the future, but she's expecting to owe more than the $65 co-pay.

"I'm really frustrated, yet as a consumer I don't have a lot of options," she said.

Though her doctor urged her to have the scan every six months, Gauntlett plans to go just once a year. It's the most she's able to stretch the carefully planned budget she maintains for her family and is also concerned about over-testing.

Some doctors worry that costs associated with breast cancer tests are becoming an issue for a growing number of women.

In 2014, Pennsylvania enacted a law that requires doctors to notify women if their routine mammograms show dense breast tissue, which appears white on mammograms and can obscure abnormalities.

Some women with dense breasts may benefit from breast MRIs or ultrasounds, which use magnets and sound waves to capture images that show greater detail.

But like diagnostic mammograms, these tests are typically subject to a health plan's cost-sharing terms.

"That's one of the problems with passing these density laws," said Somers Copit. "Imagine you get this information, and you literally can't pay — your insurance won't cover it and you can't afford it."

State Rep. Isabella Fitzgerald, a Philadelphia Democrat, proposed legislation during the last session that would require insurance companies to cover breast ultrasounds and breast MRIs for women with dense breasts. The bill didn't make it out of committee, but she plans to reintroduce the measure next year because, she said, she worries that women who can't afford the follow-up tests will skip them, possibly delaying care for a cancer that has a high survival rate when detected early.

In the meantime, it's important for women to try to understand — and plan — for costs associated with breast cancer screening, Halpin-Murphy said.

That's Gauntlett's plan.

Next year, the family's premium is going up, though the deductible will go down, and it's unclear how big a deal the new cost-sharing for imaging services will be.

"We've been blessed to be able to absorb some of these higher costs," she said.

But eventually, you have to make trade-offs.

She plans to budget less for family vacations and summer camp, instead padding out their emergency fund for any unexpected health costs that may arise.