Last year, Stephanie Halver’s primary care doctor consulted a risk assessment tool to calculate her chances of one day developing breast cancer. Halver, now 43, remembered the likelihood “popped up really high.”
That’s partly because Halver’s mother and aunt have had breast cancer. Her age and dense breast tissue also put her at higher risk
Halver, who lives in Vancouver, Washington, said her doctor recommended she get an annual breast MRI, six months after her yearly mammogram. The scan would serve as an additional safeguard, since breast MRIs can detect abnormalities that mammograms miss
Case in point, actress Olirm of cancer in both breasts, even though a recent mammogram had been clear, she told People magazine. Like Halver, Munn said her doctor recommended the MRI after a risk assessment score showed she faced a greater-than-normal chance of developing breast cancer
Catching breast cancer early, before it spreads, improves survival rates, according to the National Cancer Institute. After Halver’s insurer preapproved the scan, she scheduled the MRI for September
“Luckily, they find nothing,” Halver recalled
Then the bill came
A breast MRI — short for magnetic resonance imaging — is a preventive and diagnostic tool that captures pictures of breast tissue in higher detail than a mammogram. MRIs may be recommended for patients at an increased risk for breast cancer, including those with dense tissue, a family history of breast cancer, or certain genetic markers
But the scans are generally not recommended for women considered at average risk, according to the American Cancer Society, because they can also yield false positives, subjecting patients to unnecessary follow-up tests and procedures
Breast MRIs are also used to diagnose cancer when an abnormality is detected during a mammogram, and they can determine the cancer’s stage after diagnosis
The Bill
$1,205: After an insurance payment of $13.90, the patient was responsible for $1,191.10. The clinic also charged $65.60 for “Injectable/Oral Med,” often used to keep patients still or less anxious during the scan. Halver’s insurance covered about half of that charge
The Billing Problem: Not Always Preventive
When Halver received the bill from Vancouver Clinic, where the MRI was conducted on Sept. 26, she was confused
She knew that the Affordable Care Act requires health plans to cover preventive care, such as Pap smears and mammograms, at no cost to patients
What’s more, Halver’s breast MRI had been recommended by her doctor and preapproved by Blue Cross Blue Shield of Texas, of which she is a beneficiary through her employer-sponsored plan. The whole point of it was preventive. That’s why she assumed it would cost her nothing
To make things more confusing, a state law in Washington requires many health insurers to cover breast MRIs
“I’ve had many phone calls trying to understand” the bill, Halver said
It came down to this: The U.S. Preventive Services Task Force, a panel of outside experts that advises the federal government, is charged with recommending which screenings health insurers are required to cover at no cost to patients, and preventive breast MRIs don’t fall into that category
The task force has determined “the current evidence is insufficient to assess the balance of benefits and harms” of breast MRIs for women with dense breast tissue “on an otherwise negative screening mammogram.”
The federal guidelines are different for patients whose mammograms detect an abnormality, said Cathy Peters, senior director of state and local campaigns at the American Cancer Society Cancer Action Network
In these cases, Peters said, guidelines published by the federal Health Reg, such as ultrasounds and MRIs, are preventive
After an abnormal mammogram, these services are recommended “to address findings on the initial screening mammography” and to “complete the screening process for malignancies,”
Those guidelines are a step in the right direction, but women who have not had an abnormal mammogram may end up “running into a big bill,” Peters said. This can be a deterrent when it comes to future screenings, she said, because when “you get hit with that once, you’re going to be very careful the next time you go.”
Some states have enacted laws that require insurers to cover breast MRIs, Peters said, but they generally don’t benefit patients like Halver who are enrolled in large, employer-sponsored insurance plans. These “self-insured” plans are regulated by the federal government, not by state lawmakers
“Sadly, these state-by-state laws,” Peters said, don’t “fix the federal problem.”
The Resolution
Blue Cross Blue Shield of Texas declined to answer questions about Halver’s benefits or bill
Halver appealed the insurer’s coverage determination, and in July she received a letter indicating that her appeal was denied
Halver said she contacted her employer’s human rere covered as a preventive screening under her health plan but breast MRIs are not. That means her annual breast MRI will be subject to deductibles, coinsurance, and other cost-sharing requirements
In this case, the cost of Halver’s breast MRI was applied to her $3,300 annual deductible, an explanation of benefits from her insurer showed
“I think I’m on the hook for this bill,” she said
And because her risk of breast cancer is high, she said, “that’s a guaranteed bill every year.”
The Takeaway
If your doctor or medical provider recommends an annual breast MRI in addition to an annual mammogram, consider researching your state’s coverage rules on the DenseBreast-Info website. The nonprofit organization maintains a map with up-to-date information on state laws about breast cancer screenings. Depending on where you live and what type of health plan you have, preventive breast MRIs might be covered at no cost
If it turns out you could be on the hook for a future bill, there are a few things you can do beforehand to potentially lower your out-of-pocket costs
Ricki Fairley, co-founder of Touch, the Black Breast Cancer Alliance, recommended first finding a patient navigator at the hospital or cancer center to assist you
She urged women to seek out reincluding Touch, to find ways to lower screening costs. Programs funded by some states can help offset the cost of breast cancer screenings for low-income patients, Fairley said
Beyond that, shop around for the best price. Freestanding imaging centers may charge less for a preventive breast MRI than a hospital. If possible, also consider scheduling the MRI at the end of your health plan’s deductible year. If you’ve already met your deductible, you could end up owing less out-of-pocket
Bill of the Month is a crowd Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!
Lauren Sausserlsausser@kff.org
