Mike Fisher, the chief health care advocate for Vermont Legal Aid, said his office has gotten “a few” complaints from women who were charged hundreds of dollars for mammograms to screen for breast cancer, contrary to Vermont law.
Fisher is now asking women who think they may have been erroneously charged for their breast cancer screening mammograms to contact his office so his staff can gather more information and figure out the extent of the problem.
“State law says that women shouldn’t be charged for mammography screenings, and we believe that women are being charged,” Fisher said in an interview Tuesday. “We want Vermonters to know that they should not be receiving charges for mammography screenings.”
Cancer is the leading cause of death in Vermont, according to the Vermont Department of Health. Among women, breast cancer is the second-leading cause of cancer death in Vermont, behind lung cancer.
While experts recommend that women between age 50 and 74 at average risk of breast cancer have mammography screenings every two years, the Department of Health said that screening rates are highest among high-income women, and lowest among low-income women.
The percentage of Vermont women age 50 to 74 who had breast cancer screenings in the past two years dropped from 82 percent in 2012 to 79 percent in 2014, according to the Department of Health. And in 2014, Vermont was the only state in New England not to reach the Center for Disease Control’s goal of a screening rate of 81.1 percent.
In 2014, the screening rate among women age 50 to 74 making $25,000 to $50,000 per year was 77 percent, and 69 percent for women making under $25,000. Meanwhile, the screening rate for women making more than $75,000 per year was 86 percent.
In 2013, the Vermont Legislature passed, and then-Gov. Peter Shumlin signed, Act 25 to bar health insurance companies from charging Vermont customers out-of-pocket costs for both screening mammograms and certain procedures related to colonoscopies.
The Affordable Care Act, passed in 2010, mandates at the federal level that screening mammograms used as preventive care have no out-of-pocket costs. But Vermont’s law went further, saying that insurance companies should not be charging out-of-pocket costs for follow-up views of screening mammograms.
Fisher, who helped write the law as chair of the House Health Care Committee in 2013, said he learned in May—four years after the law passed—that patients were still being charged for the follow-up views of screening mammograms.
He said he doesn’t know why the law still hasn’t been implemented, but he’s working with stakeholders to figure it out. “It doesn’t seem to me like it should be so hard,” he said.
Fisher has engaged with the Department of Financial Regulation, which handles consumer issues with health insurance, to solve the problem. The department has put together a working group that includes Blue Cross Blue Shield of Vermont, the largest commercial insurer in the state; major health care providers; and the American Cancer Society, among others.
Mike Pieciak, the commissioner of the Department of Financial Regulation, said insurance companies have fully implemented the 2013 law, and the issue at hand has to do with both the billing codes that hospitals use and the national group that manages those codes.
Typically, a doctor will perform a screening mammogram; the billing department will then code for a screening mammogram; and the insurance company will pick up the tab for the mammogram, according to Pieciak.
However, about 10 percent of patients who get screening mammograms are called back to the office for the doctor to take another look at the images. The rub comes in determining whether that second look is considered part of the screening, which has no out-of-pocket cost, or part of a diagnosis, which can have an out-of-pocket cost, he said.
Pieciak said the issue was further complicated in January, when the national group that creates billing codes—the American Medical Association—created a code for a “screening diagnostic mammogram.” That code makes it even harder to distinguish whether the intent was to screen or to diagnose, Pieciak said.
He said the department’s working group met in August. The department has now instructed the insurance companies and providers to come up with a solution to the problem that would apply universally to Vermont’s health care system and report back to the Department of Financial Regulation.
“We left it to the provider community and the health insurer community to get meetings scheduled,” Pieciak said. He said his staff would circle back with them in September if there is no progress, but he expects to have a plan to solve the problem by December.
In the immediate term, he said patients who are erroneously charged for screening mammograms can file complaints with the Department of Financial Regulation, which would decide on a case-by-case basis whether to investigate the situation. Information on how to file health insurance complaints is available here.
Rep. George Till, D-Jericho, the obstetrician and gynecologist who sponsored the original bill in 2013, said he worked with lawmakers in 2014 to clarify the wording in the law, and that the intent has remained clear. He said he was “shocked” to find out people still had out-of-pocket costs.
“We have a significantly high rate of breast cancer in this state, and so mammogram screening is really the only chance of catching it early enough to really make it curable,” Till said. “By the time you feel it (during a breast exam), it’s probably been there 7 to 10 years. … The only way to really catch it early is with the mammograms.”
Till said: “I’m really hoping, now that we’re aware of this, that there can be work with the hospitals and the insurers to get this worked out. I hate to have to go back through the legislative process for something where the intent was quite clear. But if that’s the only way, we’ll do that.”
Till said the health care system is just “hard to move” and women’s health issues seem to be especially hard to address. “If this were about prostate screenings, would we have had this problem getting it implemented?” he asked. “I doubt it.”
