When it comes to mammograms and insurance claims, things can get a little tricky—and I’ve seen it cause more than a few headaches for both providers and patients alike.
Let me break it down. A mammogram, as we know, checks for breast health, often screening for cancer. The problem? Many facilities are billing for two services, thinking that because each breast is checked, it counts as separate. But in the world of insurance, it’s one **event**, not two. This little misunderstanding can cause some big issues when it comes to claims.
I’ve seen firsthand how these claims often get **automatically denied**. It’s not that the person doesn’t deserve coverage—it’s just that the system coding the claims sometimes flags it wrong. If it doesn’t get reviewed by a human, it might stay denied. And that’s a problem because it impacts how many visits the insurance covers, maxing out benefits unfairly.
Now, to add another layer of complexity, there’s something else that gets mixed in: the **DEXA scan**. This is a bone density test that many doctors want to do alongside a mammogram. But here’s the catch—it’s only covered under wellness benefits if you’re of a certain age. If you’re younger, you’ll need to have it covered under illness benefits, not as a routine screening. So, if your doctor suggests it, it’s important to ask why, and double-check your plan coverage.
Another common frustration? The **physician charges** for reading the mammograms often come from an **out-of-network** provider. This is where a **RAP clause** comes in handy. The RAP benefit ensures out-of-network providers are paid at a reasonable, customary rate, based on Medicare guidelines. But here’s the kicker—not all services can be covered this way. And even if they can, not every insurance policy offers a RAP benefit. It’s plan-specific.
At the end of the day, understanding your insurance coverage isn’t easy, especially when it comes to preventative care like mammograms. But with a little patience, and maybe some help from a knowledgeable agent 😉, you can get through the process without losing your mind—or your coverage!
Comments