Breast Imaging Experts Reverse Payer's Decision Not to Reimburse for Digital Mammography


The following success story provides a model that other radiologists can follow when approaching coverage problems with insurers.

When the word spread that a major Illinois insurance carrier planned to stop paying for a new digital breast imaging technology, several Chicago-based radiologists rose to the cause. The news that Blue Cross Blue Shield of Illinois (BCBSIL) would no longer reimburse for full-field digital mammography (FFDM) came via the payer's February 2004 provider bulletin, Blue Review, and was met with "shock and chagrin," said Richard Mintzer, MD, who was president-elect of the Illinois Radiological Society at the time of the announcement (Mintzer is now president).

In addition to the initial concern about a payer discontinuing coverage for a service that has its own Mammography Quality Standards Act requirements, its own certification from the Food and Drug Administration, and has shown proven value, Mintzer said he feared the BCBSIL decision would "open a hornet's nest," as other health insurers may question their own decision to reimburse for digital mammography. The ACR then learned the Blues payers in Texas and New Mexico were following Illinois' lead, as the 3 states adhere to the same medical policies to determine coverage.

Immediately, the ACR took action to address the problem, alerting ACR chapter leaders and other experts in the field of breast imaging in these states and providing them with background information to support coverage for FFDM. With the ACR's assistance in locating the appropriate payer contacts, these experts—Michael Racenstein, MD, Edward Hendrick, MD, Ellen Mendelson, MD, and Mintzer—convened a meeting with the BCBSIL medical director. The College's economics' leaders William T. Thorwarth, Jr, MD, and John A. Patti, MD helped the group prepare for the meeting, where they discussed the payer's decision to assign FFDM an investigational status, and present evidence showing the its value. "The medical director was receptive from the beginning," Mendelson said. "He was willing to meet with us, listen to our point of view, and be honest."

The group of experts also approached the issue from the payer's perspective. "We explained the difficulties we as radiologists would have [if decision went into effect], but also presented the difficulties the payer would have when it had to turn patients away from facilities that were making an effort to be state-of-the-art," Mintzer said.

The group explained that because some breast imaging facilities had replaced traditional film mammography units with those that produce digital images, assigning FFDM investigational status could impact patient access to care by forcing patients to go to another facility. They added that changing the reimbursement policy for a previously covered service could pose a financial burden to facilities that previously invested in digital mammography units, perhaps forcing them to close their doors and further impacting patient access to care.

The doctors requested that all mammography, regardless of image recording process, be reimbursed at the same rate at least until the results of the current American College of Radiology Imaging Network (ACRIN) trial were available. They suggested with this payment methodology, BCBSIL's total cost for mammography would not change since, even if the payer were to deny payment for digital mammography, patients would still receive, and the payer would still reimburse for, a traditional mammogram.

As a result of the meeting, the payer announced it would continue to pay for FFDM in all 3 states at the screen film rate. In fact, the BCBSIL medical director was so pleased with the outcome of the meeting, he extended an invitation to involve radiology representatives in future medical policy decisions. Racenstein said the secret to his and his colleagues' success is 3-fold: First, he said, "find the right person to talk with, make an appointment and follow up." Second, it is important to approach the payer with a noncombative attitude. Third, "present the hard core data that substantiates your claim. It is all well and good to take the moral high road but without the data to support your claim, they will not be too impressed."

Mintzer acknowledged that the ACR's economics leaders were tremendously helpful, allowing the experts the opportunity to discuss their strategy in a conference call the day before the meeting. This discussion armed the group with "a number of different arguments from different points of view that would advance our own belief that this is a reimbursable service," Mendelson added.

The ACR Commission on Economics maintains the following position on private payer coverage of FFDM (this position may change once the results of the ACRIN trial become available):

  • FFDM should be covered and is not investigational.
  • Digital mammography is approved by the Food and Drug Administration and thus coverage of digital mammography should be no different from coverage of digital fluoroscopy, chest x-ray, angiography, etc.
  • All of these modalities converted to digital with no change in coding or reimbursement.
  • The ACR supports coverage of FFDM at the same rate as film screen mammography.
  • The ACR Committee on Coding and Nomenclature has taken the position that if the private payer's system is not set up to recognize HCPCS codes (and therefore the G-codes that have been developed for FFDM), the technology should be billed using CPT® codes for film mammography, 76090-76092.

The ACR encourages communication at the local level between radiologists and payers, both Medicare and non-Medicare, through its CAC Network and Managed Care Network. As this experience shows, approaching payers openly and honestly can produce positive results in the end, and open the door for future dialogue. According to Patti, Chair of the ACR Commission on Economics, "this is a classic success story resulting from a well-developed national network of local physicians, which used the support and resources of the ACR in order to establish a valuable relationship with a major local payer."

For more information on working with payers in your state, visit the managed care page of the ACR Web site to obtain a copy of the Managed Care Committee's publication, Developing a Radiology Advisory Committee. If you are currently experiencing a problem with private payer coverage for FFDM in your state and would like the ACR's help, or if you would like more information on this topic, please contact Angela Stanley in the Economics and Health Policy Department at (800) 227-5463, ext 4560.