Medicare Compliance & Reimbursement

Keep compliance in mind when performing and billing screenings.

A patient receives a screening mammogram, learns that they have dense breasts, and follows their physician’s recommendation for additional screening. They schedule the study, complete it, and assume they have done exactly what healthcare professionals have asked them to do: take an active role in their health. Then, weeks later, a bill arrives.

Sometimes that bill is correct. Sometimes it is not.

Supplemental breast screening is a timely example of why claim accuracy and patient financial responsibility are not always the same thing. Federal requirements have changed, states continue to expand breast imaging protections, and proposed federal legislation could broaden those protections further. Still, the challenge is making sure those protections actually reach patients.

Dense Breasts Changed the Conversation

Since Sept. 10, 2024, mammography facilities subject to the Mammography Quality Standards Act must include breast density information in reports to healthcare providers and in patient summaries. This national notification requirement was an important step because dense breast tissue can make cancer more difficult to see on mammography and is itself an independent risk factor for breast cancer.

But notification creates an obvious next question: What happens after the patient learns they have dense breasts?

Depending on breast density, overall risk, and clinical circumstances, additional screening may be appropriate. Breast MRI, contrast-enhanced mammography (CEM), and ultrasound can all have roles in supplemental screening. Yet being informed about breast density does not automatically mean that every additional study will be covered without cost-sharing.

A patient may be told that mammography is less sensitive for them, follow their physician’s recommendation for additional screening, and then face a large deductible or coinsurance amount. For some patients, that cost may mean delaying or declining the exam. This is where a coverage issue becomes a patient care issue.

Start With the Reason for the Study

One of the most important steps is also one of the simplest: understand why the examination was performed.

Screening imaging looks for cancer in an asymptomatic patient. Diagnostic imaging evaluates a specific concern, such as a lump, focal pain, or an abnormality found on prior imaging. Supplemental screening is additional imaging in an asymptomatic patient because of factors such as dense breast tissue or increased breast cancer risk.

The modality does not determine the purpose. A breast MRI performed after a mammogram is not automatically diagnostic simply because it is an MRI. The order, indication, patient history, prior imaging, and radiologist’s recommendation all matter.

For an auditor, that clinical purpose should be the starting point. Before deciding whether a patient balance is appropriate, confirm what service was provided and why.

Then Ask About the Plan

The next question is one most patients do not know to ask: What kind of health plan do you have?

Patients usually answer with the name on the insurance card. From a compliance standpoint, that may not be enough.

Two patients can live in the same state, have cards issued by the same insurance company, undergo the same supplemental breast MRI at the same facility, and have different financial responsibilities. One may be enrolled in a fully insured employer plan subject to state insurance mandates. The other may have a self-funded employer plan governed by the Employee Retirement Income Security Act (ERISA), which generally is not subject to state insurance mandates in the same way.

When state law is involved, you must consider payer and plan type separately.

Navigate a Growing Patchwork of State Protections

States have made significant progress in expanding breast imaging coverage, but they have not taken a uniform approach. Some laws require coverage while still allowing deductibles, copays, or coinsurance. Others restrict cost-sharing, and some prohibit patient cost-sharing for qualifying supplemental or diagnostic breast imaging altogether.

That variation creates a practical compliance challenge. It is not enough to know that a state “has a law.” Staff needs to know what the law covers, which patients qualify, which plans are subject to it, when it became effective, and what patient cost-sharing is permitted.

This is also where compliance professionals can move from reacting to problems to preventing them. When a new state requirement takes effect, ask whether the change has reached registration, authorization, billing, denial management, and patient financial services. Have staff been educated? Have payer responses been reviewed? Are patient balances being monitored?

Coverage protection only helps the patient if the organization implements it correctly.

Because these laws continue to change, maintaining an accurate state-by-state reference can be challenging. One resource that may be helpful is DenseBreast-info.org. Its state insurance law map provides an easy way to review supplemental and diagnostic breast imaging coverage requirements by state, including the types of imaging covered, cost-sharing provisions, and effective dates. For compliance, revenue cycle, and patient access teams, it is a valuable starting point when researching whether state protection may apply. As always, organizations should verify the current statutory and plan requirements before making a final coverage determination.

The Federal Layer Matters, Too

The federal landscape changed for 2026. The Health Resources and Services Administration (HRSA) updated its Women’s Preventive Services Guidelines so that for plan years beginning on or after Dec. 30, 2025, additional imaging and pathology needed to complete the breast cancer screening process or address findings from the initial screening mammogram are included in the recommendation. This may include additional mammography, ultrasound, MRI, and pathology evaluation.

Under the Affordable Care Act (ACA), applicable HRSA-supported preventive services generally must be covered without patient cost-sharing by non-grandfathered group health plans and health insurance issuers.

The important word here is “applicable.” The federal update is meaningful, but it is not a blanket requirement that every patient with dense breasts receives a routine supplemental MRI at no cost. The indication, plan, and scope of the federal recommendation still matter.

ERISA generally limits state insurance mandates on self-funded employer plans, but applicable federal preventive-service requirements can still reach non-grandfathered self-funded plans. Therefore, you must evaluate state and federal requirements separately.

Check back next month for more information on navigating breast screening coverage and compliance.

Laura Manser, CPC, CPCO, CDEO, CPMA, CEMC, CIRCC, RCC