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MY TOOLS

Navigating the process can be a challenge.
These resources will help!

selfpay_health_insurance

Insurance / Self-Pay

Insurance does not always cover a screening. Most places offer a “Self-Pay” option at a lower price. To avoid any financial surprises, be sure to ask what the Self-Pay Price is before having any procedure done. 

Tips  . . . 

  • It’s good practice to always ask a provider, “What is the price if you process through insurance, and what is the self-pay price?”  Sometimes the self pay price may be less than your deductible!
  • Know your insurance service codes so you can verify the right procedure was processed through insurance. Ask your doctor’s office for the insurance code they will use for the test in question. 
  • Be sure your doctor states the procedure “is medically necessary.” When they say that, insurance is more likely to cover. You may have to insist on this, as not all doctors are aware. Additionally, insurance may be more likely to pay if your doctor uses a risk assessment model to determine supplemental screening. Inquire about risk models with your doctor.

Roadblocks To Supplemental Screening for Women with Dense Breasts

Contributing factors that prevent supplemental screening for women with dense breasts:

  • Varying Opinions:  Medical organizations recommend different things regarding supplemental screening, leaving women and doctors frustrated and confused.
  • Common Misconceptions:  For example – that a 3D mammogram (also called DBT or tomosynthesis) completely solves the issue with breast density. It does not.
  • General Confusion:  Many GP and OBGYNs are not current and are confused about the various guidelines issued by different medical organizations.

What women have reported their doctors say when they ask about supplemental screening beyond mammography . . .

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Roadblock Comment: You don’t have any other risk factors so I don’t think you need any other screening.
Your response: Density alone makes me more likely to get breast cancer. 75% of women who get breast cancer aren’t at a particularly high risk. I know that mammograms and even ultrasounds do not find all cancers present, and about 70% of women who get breast cancer have dense breasts. How can we ensure that if I do have breast cancer, that we are finding it?

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Roadblock Comment: We use ultrasound as supplemental screening, and it finds everything. 
Your Response: I know that ultrasounds find about 1 to 2 more cancers per thousand over mammography.  That is better than nothing, but I am am interested in getting something that finds more cancers than that.  Currently that would be MBI, MRI or CESM. How can I get one of those?

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Roadblock Comment:  Molecular Breast Imaging (MBI) has WAY too much radiation. It’s too risky.
Your Response: Current revisions of the equipment use far less radiation than earlier versions.  There is no research that says that this small amount of radiation is harmful.  Also, two mammograms after a call back for more pictures adds up to more radiation than one MBI – and those call backs happen all the time. 

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Roadblock Comment:  There are so many false positives with MRI. You may have to go through a biopsy all for nothing.
Your Response: I would rather take that chance, as opposed to not finding a cancer that is present but hidden by dense tissue on a mammogram.

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Roadblock Comment: It’s not considered standard of care at this point for women with dense breasts to automatically get supplemental screening. 
Your Response: I know that mammograms and even ultrasounds do not find all of the cancers present, and I would like to go above and beyond the standard of care with either an MBI or MRI or CESM.  Will you help me do that?

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Roadblock Comment: We don’t have Molecular Breast Imaging (MBI) or CESM (Contrast Enhanced Spectral Mammography), and you aren’t at a 20% or higher risk, so you don’t qualify for an MRI.  You are fine.
Your Response:  Does your risk model include density? If not, it should. What do you recommend then beyond mammograms for those of us with dense breasts, when we know that less than half of all cancers will be found by mammography, including 3D?

What To Say / Sample Scripts

What to say when talking to doctors:

Potential questions and conversation starters. Be sure to ask, learn, insist, and persist until you are satisfied with the outcome of your conversation.

What to say when talking to insurance companies:

  • First – make sure you have the same insurance code that your doctor’s office will use if applicable to the conversation. The doctor’s office should be able to supply you with this code.
  • What supplemental breast cancers screening modes do you cover?
      – Ultrasound?
      – Molecular Breast Imaging?
      – Contrast Enhanced Digital (or Spectral) Mammography?
      – MRI?
  • What are the circumstances under which each would be covered?
  • What maximizes my chances of getting these modes paid for by insurance? What do you need to see, or know?

Information to share with your friends & family

  • Know your breast density. Do you know your breast density? Find out by getting a mammogram and reading your report. The law mandates that a rating of breast density must be in that report. If it is not clear – ask!
  • Breast density increases breast cancer risk. 70% of premenopausal women have dense breasts. After age, breast density is the highest risk factor for getting breast cancer (except for women with a genetic predisposition such as BRCA1, BRCA2, etc). A woman with extremely dense breasts is 4-6 times more likely to get breast cancer than a woman who has fatty breasts.
  • Mammography will find less than 1/2 of all cancers in dense breast tissue. This includes 3D mammography – also called tomosythnesis or DBT.
  • Most cancers are in dense breast tissue. 71% of all breast cancers occur in women with dense breasts.
  • Mammography may not be enough. Therefore in some cases, mammography alone fails those of us who might need it the most. Learn more at www.mydensitymatters.org or google ‘breast density’.
  • Supplemental screening. If you have dense breasts, consider supplemental breast cancer screening. Explore the options on www.mydensitymatters.org and talk with your doctor.
  • Ask Learn, Insist, and Persist – to get what you think you need and deserve! We cannot yet depend on all doctors to do this for us, so we MUST advocate for ourselves.