What Are The Insurance Consequences If Your Doctor Orders A “Diagnostic” Mammogram?

X-RayAssuming that your health insurance has started paying for your annual “well-woman” exam, you could be confused if you still get a bill for your annual mammogram.

If that happens, your doctor’s office may tell you that your confusion is caused by a misunderstanding of the coding system.  If you are told that, you will need to know the difference between a “Preventive” and “Diagnostic” mammogram.

In this post I want to try to explain, from an insurance point-of-view, why you could end up with a bill from your hospital for something you thought would be covered.


When you have your annual “well-woman” exam, you doctor may ask for a regular mammogram.  If she does, she is doing it as a matter of course.  She does not have any reason to suspect any problems.  She is just requesting the mammogram in case there is something growing in your breast that should not be there.

As deadly as breast cancer can be, giant steps have been made in its treatment since I started in insurance.  When I began working with insurance in 1987, surviving breast cancer was rare.  Less than 10% of patients survived for longer than 5 years.

Today, things are much different.  Breast cancer, if diagnosed early enough, is still annoying and treatment can be painful and frustrating.  However, survival rates are significantly improved.  According to the American Cancer Society, more than 88% of women diagnosed with breast cancer are still alive 5 years after their battle if the cancer is “caught” while it is still in “stage 1.”


A diagnostic mammogram is ordered by your doctor when there is reason to suspect that there is a problem and your doctor wants more detailed information.

If your doctor orders a “Diagnostic Mammogram” don’t necessarily be afraid.  Just because your doctor wants a more detailed look, does not necessarily mean that she is expecting to find cancer cells.

Under Obamacare only “Preventive” mammograms are subject to the new rules.  However, if you get a “Diagnostic Mammogram” it will be subject to your health insurance deductible.

My wife has a “benign” (non-cancerous) cyst that manifests as a “lump.”  Although it is, and never has been, cancerous, her doctor prefers to get a “Diagnostic Mammogram” every other year.  If something changes, her doctor wants to find out early.

The problem is that many Americans tend to get confused and blame their insurance company when the bill at the hospital is not paid.  If that has happened to you, here are some steps that you can take to see if there is a problem.

  1. Contact your health care provider to find out if you got a “preventive” or “diagnostic” mammogram.
  2. If your mammogram was indeed “preventive” verify that your health care provider coded it accurately when the claim was sent to your insurance company.  (Remember, they cannot be held responsible for mistakes that were made in your doctor’s office.)
  3. If the claim was mis-coded and a new, correct, claim has been submitted to your insurance company for a “preventive” mammogram it should be paid.
  4. If your claim is still not paid by your insurance company after you have confirmed that your mammogram was “preventive,” call you state department of insurance and file a complaint with the consumer affairs division.  However, before you go to that extreme, make certain that you have a full understanding that only “preventive” mammograms and not “diagnostic” ones are covered under the new A.C.A. rules.  Remember that “Diagnostic Mammograms will still be subject to your plan’s deductible.

If you read this far, you are probably concerned about what to do if you are diagnosed with breast cancer.  I cannot offer guidance on the emotional reactions that you and your family should make.  However, I am able to help with the additional bills that health insurance does not pay if you do some advanced planning.

Click the banner below to review, and apply for, Critical Illness insurance.  It will pay a lump sum of money directly to you if you are ever diagnosed with cancer.  You can use that money to pay for anything you want, including a “Diagnostic Mammogram.”

Critical Illness
Available in TX and IN through The Insurance Barn.

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