Some patients with Medicare are now being charged for breast ultrasounds, physicians say
NEW YORK -- Local physicians say patients are now noticing new charges following annual breast cancer screenings.
Patients who rely on Medicare coverage say they've never been charged for receiving ultrasounds in place of mammograms until recently.
"I was absolutely shocked, I gotta be honest," Forest Hills resident Barbara Glick said.
Glick is talking about an email from her doctor's office at Weill Cornell Medicine stating she will now have to pay $175 for a breast ultrasound. It's a charge the Queens resident says she's never had to pay before under Medicare.
"I have to pay for something that used to be covered that I desperately need to rule out any cancers," she said.
According to the National Cancer Institute, nearly half of women in the United States over the age of 40 have dense breasts, such as Glick. Many doctors recommend those women opt for a yearly ultrasound in place of a mammogram, as they have a higher risk of developing breast cancer.
"Having dense breasts makes your mammogram harder to read and harder to catch cancer, in addition to increase your risk of ... developing cancer," said Dr. Cindy Lee, chief of breast radiology at Stony Brook Medicine.
She says Medicare is charging patients for a test that was typically covered in the past, and that more insurance companies are following suit.
"We've been seeing more and more patients coming in ... once a year for their screening ultrasound only to find out a month later that the insurance has dropped the coverage," Lee said.
Lee says she is required by law to tell her patients with dense breasts to consider supplemental testing such as ultrasounds.
The email Glick received reads in part:
"Medicare recently informed us that having dense breasts alone is not enough reason for them to pay for breast ultrasound. If you proceed with an ultrasound and the only reason you are having this exam is due to dense breast issue, Medicare will NOT cover the costs ...
"Medicare will still pay for breast ultrasounds for other indications such as if an ultrasound is needed to diagnose a problem, or if the person has current or prior breast cancer."
"Medicare is coming back and saying, well, sorry, I know you need this test but I'm not going to pay for it. So it's such a contradiction when it comes to policy," Lee said.
"I have a good possibility of getting breast cancer and never knowing it. Never knowing it, or I have to pay," Glick said.
Casey Schwarz, with the Medicare Rights Center, says the ultrasound charge is not due to a recent policy change, but rather insurance providers taking a closer look at patients' claims.
"The local coverage determinations that are currently in place have been in place for a number of years and there's been no change in the U.S. preventative services task force recommendations," she said.
Schwarz explains a mammogram is 100% covered because it is a screening service, while an ultrasound is not fully covered because it is a diagnostic service. Although, she says patients should not be charged 100% of the cost, rather a cost-sharing fee, or co-pay. She recommends patients speak with their clinicians to ensure the ultrasound is listed as a diagnostic service in the claim.
"It shouldn't be denied entirely, meaning you're fully responsible for the cost of the care," Schwarz said.
Meanwhile, Lee says the lack of full insurance coverage is a major socioeconomic barrier for millions of women.
"These financial costs are significant. They're falling on our poor patients, and they're really starting to limit the access to for a very essential test," she said.
Although Medicare states having dense breasts alone does not qualify for coverage, Medicare will cover the cost of the ultrasound for other indications, such as if an ultrasound is needed to diagnose a problem or if the person has breast cancer or had it in the past.
