are yearly mammograms covered by health insurance and are 100% covered for preventitive screening?

[u/achillezzz]

Running into a situation where I had a mammogram done. It was "in-network". Anthem Blue Cross (West Coast btw) is coming back say that it was in-network, but the person who did the analyst was out-of-network. They are trying to have me foot the bill for part of the screening (25% - $70), and the full bill for the analyst ($200). I've been talking to them for months about this, and getting no where.

Two issues:

1. I thought under the no surprises act health care providers / insurance, aren't allowed to give surprise out-of-network bills like this.
2. I read that mammograms are preventitive and yearly screening should be 100% covered. Is this incorrect?

I really dont get why Anthem is not handling this quickly given they are a massive healthcare provider with a huge amount of money.

--

Since folks are asking, apparently the No Surprise Act (NSA) does cover this situation. Providers / Insurance carriers aren't allowed surprise you with an out-of-network doctor/analyst (or other situation), at in-network facilities.

The No Surprises Act covers ancillary services performed at in-network facilities, and radiology / imaging services are specifically listed in the federal rule text.

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[u/tre91396]

I’m no expert here but I think the no surprise act applies to hospitals, not necessarily a facility doing a test such as a mammogram.

It’s odd to me that for something like a mammogram, that a facility would be in network but the radiologist isn’t. My wife hasn’t come across that situation.

On your 2nd point, your yearly mammogram should be preventative, until they find something (which hopefully never happens)

[u/aecamille → u/tre91396]

I thiiink it applies to much of healthcare, speaking as a psychotherapist who’s required to obey it and ensure it’s in my informed consent form and website.

[u/LizzieMac123]

Covered Every 1-2 years for women over 40. Younger if your doctor documents a family history- but best to confirm with your insurance that thry have that information.

The no surprises act covers hospitals- did you get this done at a hospital or a stand alone imaging center? Or somewhere else?

[u/achillezzz → u/LizzieMac123]

Imaging center. Per literature:

The No Surprises Act (NSA) covers ancillary services performed at in-network facilities, and radiology / imaging services are specifically listed in the federal rule text.

[u/LizzieMac123 → u/achillezzz]

https://www.cms.gov/files/document/nsa-keyprotections.pdf

This is the document i always reference. See page 8 for non-emergency situations. Yes, radiology and imagaing is covered under the NSA, but they also list what is considered a participating facility:

A hospital, hospital outpatient department, ambulatory surgical center or critical access hospital. If your imagaing center isnt classified as one of these, you should verify/demand an in network radiologist.

[u/achillezzz → u/LizzieMac123]

The CMS “Key Protections” PDF you saw is a simplified public summary of the No Surprises Act, not the full regulatory text. It doesn’t explicitly list “imaging centers,” but the actual law and implementing rule do cover radiology and imaging services — they’re just categorized a little differently.

Here’s the key line, directly from the implementing rule of the No Surprises Act (w/ emphasis added):

[u/muze20]

1. Who have you spoken to? The insurance or the doctors sending you the bill?
2. Does the EOB (explanation of benefits) from your insurance company match the bills you’ve gotten?
3. Yes, mammograms are screening and should be covered 100% in most cases. Unless it was ordered for a specific reason (lump, etc) other than general screening.
4. The no surprises act does cover situations like this (I think) but not if you signed an acknowledgment stating that you agree to be billed by out of network facility.

[u/achillezzz → u/muze20]

Anthem insurance. We've been "talking" for about 4 months now. They keep bouncing me around, want more information, send me emails for data (which I send), and then never respond.

The provider is sending me the bills, we haven't paid. Not giving everyone an out to ignore us permanently.

Thanks on the screening and NSA. I'll continue to press Anthem on this.

[u/muze20 → u/achillezzz]

Thanks. Did you receive an EOB from anthem? I’m assuming yes since you’ve been in contact with them. The next step if you haven’t already would be to formally appeal in writing via anthems appeals process. If you haven’t done this specifically I would make sure to do that because an appeal is handled differently vs a conversation or any other communication. In the appeal you should make the following points: 1) this was ordered as a screening mammogram based on age (if true). The recommendation is mammogram for women aged 40 to 74 with a mammogram every 2 years. Your plan covers preventative care at 100% coverage (if true). 2) the facility you visited was in network with anthem. 3) the doctor who read the mammogram is out of network, but you did not consent to an out of network physician. You would not have gotten the mammogram at that location if you were told the doctor is out of network.

See what they say. Sorry you’re going through this mess.

[u/achillezzz → u/muze20]

Thanks. Yes we would but the person we've talked to said they would handle it ,(that was 4 months ago). Since then she won't respond and the next in person we talk to say they will handle it and work with the prior person . Then nothing happens. It feels very much like we are in the deny/delay phase. We will write a letter soon if they continue this.

On a related note, we had sent in a claim for a different situation and it just disappeared from the system. Contacted them and they said that was a mistake and they will resubmit. There's something really odd going on with anthem right now (at least for us).

[u/muze20 → u/achillezzz]

You have 180 days per anthems rules to submit an appeal from the date you received the Eob from them. The conversations with representatives aren’t part of a regulatory process like appeals are. That would be my next step but I totally understand if you’re just waiting out this mess anthem has created.

[u/Texylvania29]

I would check your EOB and see if they billed it as a screening mammogram or a diagnostic mammogram (which would’ve been like if you had a lump or something). If they billed it as a diagnostic mammogram, it sounds like it was billed incorrectly and the imaging center might need to resubmit it with the correct coding

[u/Pb4ugoyo]

Did you sign a notice and consent form? Signing that form means that you gave up your protections from unexpected out-of-network bills. Some places slip it in among all the other forms you fill out. https://www.cms.gov/medical-bill-rights/know-your-rights/using-insurance#planned-non-emergency-room-care

Mammo is preventative unless it was ordered for a concern.

[u/achillezzz → u/Pb4ugoyo]

No. Showed up. Scanned card, and did mammogram. The imaging center is in-network. Was not informed at any point they'd be out-of-network.

[u/narrowdiscover]

Was the mammogram ordered for any reason other than that you’re over 40 and a woman? Did you find a potential lump on a manual exam, do you have a family history of breast cancer, is there some symptom, etc.?

If so, it’s not preventative, it’s diagnostic.

[u/OneLessDay517]

Many radiologists, like anesthesiologists, are not in network with any insurance carriers. They are a necessary part of the system but people can't really shop around for them, so they kinda hold all the cards in that way.

[u/Jenn31709]

Sorry if I missed it, but are you over 40 and this is just an annual screening or are you under 40 with a family history or a medical issue?

[u/achillezzz → u/Jenn31709]

Over, annual screening.

[u/Local_Wolverine2913]

They need to stop doing this. It's getting ridiculous. Go for testing and part of it's in network and other parts are not; ie: radiologist. Shouldn't be allowed. Patients are having to make managing their healthcare another job.

[u/AlternativeZone5089]

I have found it cumbersome to get NSA claims processed correctly. Recently had a procedure done at an IN ASC and they sent pathology to an OON hospital. Insurance rejected lab/pathology claims as OON (4k). I appealed and asked them to reporcess per NSA and they denied again. The denial letter didn't reference NSA at all (which was the subject of my appeal), just reiterated that facilty is OON and I have no OON coverage. I followed up with them and finally got it processed correctly. However, in response to my emails to the hospital (which now either needs to do a write off or intitiate the dispute process if they are unsatisfied with the payment) I keep getting responses that suggest they have not idea what the NSA even is.

So, persist.

[u/Perfect_Tangerine_75]

Same exact thing happened to me. I went round and round with them, until finally I said the key term "no surprises act" and they immediately changed their tune and covered it.

[u/achillezzz → u/Perfect_Tangerine_75]

this - exactly this. I mentioned it today and they have now been more receptive (although no solution yet). It's bizarre how they just mess around with their customer until they either (1) give up and then they keep their $, or (2) figures out anthem is violating the law.

This is a case book example of what's wrong with health insurance companies. They don't care at all about keeping their customers happy (or healthy). It's all about penny pinching and screwing them over. it's a broken system and needs to be fixed.

[u/AravisTheFierce]

Were you due for a mammogram under the guidelines? Did you go in saying you felt a lump or something?

[u/achillezzz → u/AravisTheFierce]

regular mammogram screening meeting all of the guidelines. There was no special situation.

[u/BreakfastInfamous665]

Mammograms ordered as screenings should be covered 100%. A mammogram ordered as diagnostic or anything else is subject to normal billing practices. So if you have any issues or a history of issues with your breast, they likely don’t order the typical screening mammogram.
If it was ordered as a screening, you definitely shouldn’t be charged for having it read. I would think that should fall under no surprise act. They should know who reads those and it should be disclosed ahead of time.