Why Did You Have to Pay for Your Mammogram? The Costs Involved.
When it comes to breast imaging, not all mammograms are billed the same. If you’ve ever gone in for a routine screening and ended up with a surprise bill afterward, you’re not alone. The reason often comes down to a key distinction between screening and diagnostic mammograms.
At a glance, both involve the same technology. Both use X-ray imaging to look for signs of breast cancer. But insurance doesn’t see them the same way, and that difference can impact how much you pay out of pocket.
What is a screening mammogram?
A screening mammogram is routine. It’s meant for women who have no symptoms and no current concerns. The goal is to catch breast cancer early, before it causes noticeable changes or spreads.
Under the Affordable Care Act, most insurance plans are required to cover screening mammograms at no cost to you starting at age 40. That means no co-pay, no deductible and no coinsurance as long as it’s truly a screening.
What is a diagnostic mammogram?
A diagnostic mammogram happens when there’s something specific to investigate. Maybe you felt a lump. Maybe your doctor noticed a change. Maybe your last screening found something suspicious. A diagnostic mammogram takes more images from different angles and often includes additional views or an ultrasound.
Because it’s considered follow-up care or problem-based imaging, insurance companies treat it differently. In most cases, a diagnostic mammogram is subject to cost-sharing, which means you may have to meet your deductible, pay a co-pay or cover coinsurance.
Even if you didn’t request anything different, your screening can be reclassified as diagnostic depending on what the radiologist sees during the visit.
Why it matters
For many women, this distinction feels arbitrary and unfair. You go in for a covered screening. They spot something that needs more imaging. Suddenly it’s diagnostic and you’re holding the bill.
This policy gap can discourage women from following up on findings. Some delay additional imaging because of cost. Others are blindsided by charges they weren’t prepared for. It’s a problem that hits especially hard for people with high-deductible plans or limited income.
What you can do
Ask upfront whether your appointment is classified as screening or diagnostic
Check your insurance policy to understand how breast imaging is covered
Know your rights under state laws, as some states now require coverage for diagnostic imaging
Appeal bills if you believe a reclassification was made without your informed consent
Access to breast imaging shouldn’t be compromised by billing codes. A follow-up that could save your life shouldn’t come with a financial penalty. Knowing the difference between screening and diagnostic mammograms, and how insurers treat them, can help you make informed decisions and advocate for the care you deserve.
