For the Ladies - Breast ultrasounds/dense breast tissue
Hi Ladies! (And gents if you so dare)
Any of you girls lucky enough to have dense breast tissue? Is your mammogram technician trying to "sell" you a breast ultrasound stating that there is a new "law" now that mandates breast ultrasounds be covered by insurance? DON'T believe it!! I fell for it hook line and sinker (that one was for the boys reading) and now I owe the facility $1100.00+ (facility to remain nameless - for now)
Any other victims out there who were misled like me?
Dallas I have an ultra sound done as well as a mammogram due to dense breast tissue but my doctor has always written a prescription to have it done. I never heard of a technician being able to make that decision and do the ultra sound without one.
Sorry you were taken advantage of. Especially when we all know how anxious we become having it done in the first place.
Ollie Hi Dallas, sad but true. If you have a New Jersey based insurance, it must be covered. Example would be state employees. Work for a company that is self insured, they probably fall under federal law and it may not be covered. Shop it or maybe die, I guess is the final analysis.....
maja2 
Calico696 No problem since 3-D mammos arrived - used to have call backs - no longer - but haven't been sent for ultrasound - and wouldn't go without doctor prescription -
4catmom I have the dense tissue situation as well. Last year I got the mammo & ultrasound, both were covered by my insurance and my portion was $0. I don't remember if the tech told me about it and whether or not I had an order from my doctor for the ultrasound. I don't think I did. Due to them finding a cyst, I had a follow up ultrasound 6 months later, my doctor ordered it and my portion to pay again was $0.
Lynnada I have been doing both for a few years now. The dr. writes the script. I pay nothing as well.
JL My Dr. always writes on the script "Ultrasound if indicated", now I just schedule both on the same day since I know I will have to have it anyway, no way in hell I am going back twice in a year, I stress over it enough as it is. My insurance covers both. Hopefully you can get it straightened out with the facility, since you were advised by their staff that it was covered. If they told you that, I'm sure they told others and are probably getting a bunch of calls.. Good Luck
JrzyGirl88 If your mammogram shows something abnormal for the first time during routine, yearly test, then ultrasound is performed immediately on a request of radiology doctor (the one who read your mammogram, not a technician). It should be covered 100% because it falls under preventive service. If ultrasound confirms abnormalities, cysts for example, all yearly mammograms must be done together with ultrasound at the same time at the same facility. I emphasize on "must", because there is a special protocol for breast cancer prevention and diagnosing . No facility will schedule and perform only mammogram (regular, digital, or 3D) without ultrasound if you have a history when mammogram has required immediate ultrasound. You have to mention it to your physician or OB/GYN and they will prescribe these tests together (often they forget), and specifically tell receptionist that prescription is for "yearly tests". Lately radiology offices decided to bill such an ultrasound under a different code - as a diagnostic procedure, not preventive procedure because they are paid much less. Before paying anything to radiology office,call your insurance company and request explanation of benefits (what services were billed and how insurance paid them). If procedure was billed under incorrect code - call your insurance company and appeal. Don't pay yourself anything if you had ultrasound on a request by radiology doctor who was reading your mammogram (first time finding). If you will be recommended follow-up mammograms with ultrasound (in 3-month, in 3-month, then 6-month, then 6-month, then at some annually) then your insurance company might treat them as a diagnostic procedures and may pay or not pay depending on your insurance deductible. Or depending on the diagnosis. Have follow-up mammograms and ultrasound performed at the same facility or take all films and reports with you if you will be going to a different facility. At the end - these tests are done not because someone wants you to pay them but because you want to be sure you are OK.
Lena The past few I had I needed an ultrasound done right away. No one tried to "sell" me anything. I was told it was needed (after redoing one side of the mammogram...double ouch!), it was done, and insurance covered it with no issues.
SueR Yes, I have ultrasounds in addition to my mammos.
"Dense breast tissue" is the DIAGNOSIS and is what makes you eligible for the US.
The US is part of your ROUTINE preventative annual care and must be BILLED that way, using procedure code ***77052***.
Any other procedure code will not generate "routine preventative annual care" and then may not be covered.
Really???Thanks for that ladies. Did appeal with insurance..... denied. Asked facility for "forgiveness" .... denied.
I guess they'll get $5 per month for a long time.....
Frustrating and sad
Appeal again using information above and provide correct billing code. If needed tell facility to re-submit a bill with correct billing code. If they decline, tell you will fill out an official complain about their billing practices with a board. Speak to insurance supervisor. It takes time. I absolutely hate these procedures that give a physical pain and billing pain. Don't forget, if you will agree to pay now, you will always pay for all your next tests. Also radiology and anesthesiology offices are very prone to send your bill to collections after 3 months and they don't give you any discount to pay a lump sum. It's very sad to see how much insurance pays for US and office accepts the pay (15% max from the bill) and they want 100% from you.
A corrected claim is my last resort (if I can even get them to re-file) I just have no time to deal with this bull sh*t. I even tried to file a complaint against the facility but they don't handle/deal with "billing" issues. Tried to tell them that it was not a billing issue ....but an issue of a woman being taken advantage of..... they wanted none of it.
I'm ignoring the bills at this point but at some point I'm going to have to make a decision
Why are you dealing with this yourself? I forward any issues like this that arise to my company's insurance broker. They are well versed with the insurance laws and know whom to talk to (and how to get them on the phone) and usually get it straightened out right away. Usually costs me a couple of expensive flower arrangements every year, but it's money well spent, IMO.
ianimal ianimal - I did reach out to the insurance broker way back at this beginning of this nonsense. She's the one who told me to appeal. Maybe I have to get her involved again. Thanks for pointing that out :-)
I get both with no problem. I didn't need to be sold on it.
"By guaranteeing coverage for breast sonography, the legislation intends to reduce the number of patients who may decline [the exams] in order to avoid out-of-pocket expenses," the two wrote. "As expected, and confirmed in our data, this has led to a significant increase in the numbers of those undergoing screening ultrasound examinations, resulting in an increased overall reimbursement amount."
http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=112003
Never count on your broker to *fight* for your money to be returned as hard as you will fight, no disrespect to insurance brokers (my husband is one... he agrees, that's just life). The reality is that no one will ever fight for you as hard as YOU will. As someone who has a lot of medical issues, I can tell you categorically that the insurance companies *automatically* deny ALL special requests, bar none, on the first time around. They may bar it on the 2nd appeal. Don't let it stop you. I sure wouldn't! Try to look at it this way. If it takes you 3 hours to prepare the letter, and you have to write two letters, you just earned $183 an hour!! That's a pretty high paying job AND a job that bought & brought you peace of mind. I would use all of the fabulous detailed information provided here by these wonderful ladies, and USE it to absolutely destroy your opponent. BTW, I would send the letters signed, return/receipt/request, VERY business like, cc the Better Business Bureau, the NJ Insurance and Banking Commission. I would actually be running TWO campaigns, 1) that you shouldn't have been charged in the first place (those letters to the facility, copies to the BBB, etc, 2) fighting the insurance company with the information above... This must be run concurrently due to the time limitations on insurance claims. Best of luck to you! I can promise you that if you badger them, I think your BEST bet, from the brief description/information available, is the facility. Make them miserable. Be smart, calm, cool and collected and GO GET EM, GIRL! PS... try to look at the bright side, you learned a valuable lesson. No matter how much anyone plays on your emotions, unless it's a life threatening situation, there's nothing that can't take a few hours to think about.
Sunshine615 Maybe you should have checked it out with your insurance company before having it done?? I'm sure you weren't forced. Never just assume.
Howboutit Howbputit - I was in a similar situation, and yes, I was forced to have ultrasound immediately after mammogram because mammogram was not sufficient for radiology report and the facility had to follow a protocol for such cases. And that's why both procedures should be billed as a bundle, and be covered 100% if done during yearly mammogram.
Actually, since men also get breast cancer, though obviously at a much lower rate, I believe most would have to go right to a sonogram, since a mammogram isn't usually practical for a man due to lack of tissue and what tissue they do have is usually rather dense to begin with. if a lump is felt, I don't think a man would get this kind of diagnostic tool refused by the insurance company.
Phil D. With all due respect Lena .... "Forced" ?!
No one can force you to do anything you do not want to do. Strong word to use
Wow howboutit - Let's not turn this ugly
Of course no one can be forced to do something, but, when they have us questioning our own breast health and offering reassurances via testing, it would normally be a no-brainer. And of course, had I checked with insurance before hand, I wouldn't be in this situation.
As they say, hind sight is always 20/20. Lesson learned. Just trying to spare anyone else out there the same outcome.
I'm willing to bet is that someone at the radiology clinic put down the wrong diagnosis or code and the insurance company rejected it out of hand. I've also found that the people who work in billing for these places are miserable and assume that you are trying to get out of paying what you owe, and you very rarely get anything but aggravation by attempting to deal with them yourself. Don't ever waste your time arguing with the billing department of the provider. They'll always insist they did everything right and that you better pay up or they're sending you to collections.
A good insurance broker (I'm pretty sure I have the best... love you, Karen at MetLife) has contacts in the insurance company who can determine why a claim was denied, and in just about every single problem I've ever had, it was a data entry error on the part of the provider.
The only other issue I've run into are anesthesiologists and emergency room doctors in "in-network facilities" who were out-of-network and trying to bill me crazy amounts. Karen fixed those issues too by getting the insurance company to negotiate a settlement price with the provider somewhere between the contract price and the price he was charging that satisfied the debt in full, and I never paid a cent.
Turn this ugly Dallas?
Wow. Considering someone who is claiming to be forced to have a procedure done that is being "sold" by the ultrasound technician. What if the results weren't what you got? That $1100 bucks/ultrasound technician scammer could have saved your life.
Horrible
ianimal - I emailed my ins rep. She advised to try and get the facility (still remaining nameless) to do a corrected billing so (hopefully) insurance will pay. I guess I'll have to dig up all that paperwork again and make that call on Monday. Just so frustrating that it consumes so much time for one simple procedure/billing.
I almost think that's exactly what the provider wants .... make it as frustrating as possible so that the patient will just pay the bill to be done with it. Getting close
SAHM - First, I never said I was forced to do anything. Read my post. I was absolutely "sold" an ultrasound by a technician. That is my whole point with this post. I was misled.
As far as the results, that is something you will never know now will you. How do you know it didn't diagnose cancer.
Horrible
I'm sorry to hear about this story.. I work in the medical field and know first hand how important it is to give a patient all options when it comes to cancer screenings.
Sounds like you weren't given all the information up front.. but keep in mind if you declined the US and something was there and only seen via an US then you would have had a bigger issue.
It's a very tough call for hospitals and facilities to deal with.
I hope this facility helps you with this bill.. $1100 seems extremely high for an US.
It's a shame all women are guaranteed coverage for breast cancer screenings in 2016.
Good luck Dallas.!
Meadowlane Good luck Dallas. I hope you can get everything straightened out. You don't need anymore stress.
If you advise the radiology facility that you are appealing the denial they will postpone sending your account to collection. Call them once a month and advise the same thing til it's resolved.
I had a normal mamo done and the tech suggested I have an ultrasound due to my dense breast tissue. I'm glad I did because they found something. I went for a biopsy and luckily it was benign. i now have a titanium clip in my breast for future reference. I know this was a little off the op topic but please ladies always get checked even if mammo is clear and you have dense breasts. Ultrasound will pick up more info.
Natari Natari, I've had the same thing done. I have 3 in left side and 2 in the right. So glad I had the ultrasound and the mammo as well.
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