QUICK TIP--DUE DILIGENCE/HEALTHCARE — The Consumer Playbook

I love the seasonal transition to warmth when spring arrives. Bears have it all figured out—they hibernate for the winter. Apparently, so do chipmunks. (Not being an animal specialist, I did a fact check on bears and found out about the chipmunks. So, new knowledge for those who are interested.) Bears and chipmunks get it right. If I could hibernate during cold weather, I would. But I can’t, so here I am now, happy with spring. The downside of spring is that I have a long list of semi-annual maintenance chores. Car service, dental check, heating/cooling maintenance. And mammogram.
I just scheduled my annual screening mammogram at a hospital that I haven’t used before. Since I didn’t know their system and protocols, I did my due diligence:
1) Do they do 3-dimentional mammogram (tomosynthesis)? This is a newer technology that most facilities include as part of a screening mammogram. If this is part of the protocol, is it covered by my insurance?
2) Do the doctors who read the mammogram participate with my insurance? Is the facility In Network?
A few points to consider:
1) Under the Affordable Care Act, Preventive services, including annual screening mammogram, are covered without patient cost--only if you use In Network providers. (I hate the term “provider”. It diminishes the expertise of medical professionals. Remember, medical professionals who treat you are just that—trained professionals. They’re not science fiction robots or chattel.) I made sure that the hospital is in my insurer's network. I asked whether the radiologists who read mammograms participate with my plan's network. The scheduler didn’t know and gave me the number for Radiology Billing. I’ll check with them to make sure that they are part of my insurer’s network. If they’re not, they can bill me for reading the study. If I find that they are Out of Network, I’ll see what I can do to negotiate charges up front.
2) Is tomosynthesis covered by my insurance company? Many insurers consider it investigational and won’t cover it. At work, I’ve found that for carriers who don’t cover this procedure, if a patient appeals, more often than not, the coverage denial is overturned on external appeal. This means that within the carrier appeal process, it usually remains denied, But since external appeals are reviewed by a neutral 3rd party, those appeals usually result in coverage. At some point (hopefully soon) this probably won’t be an issue, since it’s moving into standard of care. But some insurers just stand on their hardline coverage criteria. I called my insurance company, gave them the procedure code (which can be obtained from the facility or radiology group) and found that it is covered. When the procedure isn't covered, some physicians and facilities write off the charges—which range from under $100 to a few hundred dollars. But some don't. Better to plan where possible.
The issue of hidden services and possible hidden costs comes up all too frequently. See the healthcare section of my book, The Consumer Playbook, for more information on how to avoid problems when possible and how to deal with them on the back end if you can’t avoid them.
A LITTLE BIT OF DUE DILIGENCE UP FRONT CAN GO A LONG WAY IN AVOIDING HEADACHES LATER