If it is not a crisis yet, it soon will be. Mammography centers around the country are closing their doors. In New York City, the wait for a diagnostic study is as long as 6 weeks, and the wait for a screening study can be several months. One university program there closed a facility that it continues to rent because “it would be less expensive to pay rent and not treat patients than to perform mammography,” according to Gillian M. Newstead, MD, director of breast imaging at New York University Medical Center. Women’s health experts fear that the long waits for screening studies will discourage women from having regular mammograms, leading to delayed diagnosis of breast cancers.

The problem is money. Medicare pays a facility a Congressionally mandated average of $68 for a screening mammogram and $81 for a diagnostic study. Most private payors follow the government’s lead-at best. Some HMOs require radiology practices to accept very low rates for common examinations such as screening mammography in order to gain higher reimbursement for others. At Boston Diagnostic, which calculates that a mammogram costs them $90 to perform, one insurer reimburses less than $35.1

The consequences of these reimbursement practices were recently documented by Dieter Enzmann, MD, chairman of the Department of Radiology at Northwestern University Hospital in Chicago. He surveyed seven academic institutions that perform 10,000 to 50,000 mammograms per year. “Every one of these institutions lost money on mammography services,” he told a press conference at the 86th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA) on November 30, 2000. “The losses were in the hundreds of thousands of dollars per year.”

Other panel members at the press conference agreed with Ellen B. Mendelson, MD, chief of mammography and women’s imaging and director of the Breast Diagnostic Imaging Center at Western Pennsylvania Hospital, Pittsburgh, that unlike the usual situation, in which economies of scale are realized, with diagnostic mammography, “the more you do, the more you lose.” Some facilities are able to make a small profit on screening mammograms, but at others, including Memorial Sloan-Kettering Cancer Center in New York, screening mammograms also are unprofitable.

Are we going to lose the gains we have made against breast cancer by using mammography? Special sessions at radiology meetings in the fall of 2000 offered help to those struggling to keep their facilities from going broke.

Know Your Costs

Although it often is difficult for a hospital-based breast imaging center to determine, each facility needs to know what it spends to provide each service it offers. Both direct and indirect costs must be calculated. The direct ones are obvious: the equipment and its maintenance; medical supplies, including film; and personnel (technicians and radiologists), including salaries, benefits, and malpractice insurance. At one breast disease center, direct costs are 58% of the total facility costs, with radiologists and technologists accounting for 35% of the total facility costs. Many of the indirect costs are less obvious, and include office staff salaries, benefits, and continuing education; regulatory compliance (ACR/Mammography Quality Standards Act [MQSA] compliance staff and documentation); building rent, maintenance, and cleaning; office equipment; supplies; and outside personnel (accountant, lawyer, consultant). The total indirect costs are distributed among the procedures offered at a center. The total direct and indirect costs for each procedure (mammogram, sonogram, core needle biopsy) are then calculated.

Table 1. A listing of the Hospital Outpatient Payment System codes for breast procedures.

At the RSNA, in an educational session entitled “How to Organize and Run a Profitable Mammography Center,” Wende W. Logan-Young, MD, director of the Elizabeth Wende Breast Clinic in Rochester, NY, discussed the utility of radiology assistants and of making maximum use of technologists.

“I cannot overemphasize the importance of the radiology assistants,” Logan-Young said. “If the radiologist has work that can be done by someone else, such as putting films on the viewbox or taking them down, dialing the telephone, telling physicians about the results of a study, explaining procedures to patients, these assistants do it.”

The Wende Breast Clinic has 16 assistants. Each radiologist who is seeing diagnostic cases has two assistants. Only a high school education is required for these jobs, and many of the assistants begin as front desk staff.

“They need to be savvy, and they need to be quick and compassionate,” Logan-Young said. The assistants receive about a year of training.

A member of the audience noted that he has some assistants who are volunteers, many of them breast cancer patients.

The Wende Breast Clinic also has technologists who do more than is the usual practice. For example, most ductograms are done by technologists. The technologists also do all of the preparations for a core biopsy.

Logan-Young suggested that a center resist any temptation to establish satellite clinics or use vans, at least in its early years.

“Unless the satellite facilities are very busy from dawn to dusk, they do not make enough money to justify their cost,” she said. She noted, however, that satellite facilities are less in demand in Rochester because the freeway system puts the Wende Breast Clinic within 15 minutes of almost every woman in town.

Computer expertise also helps keep costs down. Bar coding assists in keeping films and paperwork together. For screening mammograms, the clinic uses a standardized report that is sent by fax to the referring physician’s office directly from the computer. Only a few keystrokes are required to produce the report, reducing the number of transcriptionists the clinic needs.

William R. Poller, MD, FACR, director of radiology at the Magee-Women’s Hospital in Pittsburgh, another speaker at the RSNA session, called attention to the costs of obtaining and returning outside mammography studies.

“Are you willing to read the case without the outside films?” he asked. “It would be ideal if I had 100% of the films from 100% of the patients, but you know that does not happen.” If a radiologist must have the films, he suggested asking the patient to bring them and to sign a permanent transfer so that the films need not be sent back and need not be retrieved for future mammograms.

Another ingredient of cost minimization is to look carefully at the callback rate, which increases overhead. Poller suggested asking radiologists with an unusual number of callbacks what they can to help lower the rate.

“You want to do the correct thing for the patient, but you should not be an outlier in either direction,” he pointed out.

Work with and Educate Clinicians

Education of referring physicians helps facilities reduce costs and obtain reimbursement. Referring physicians should be taught which imaging studies are appropriate in given circumstances and know that they must provide a specific clinical diagnosis if a patient is being referred for diagnostic studies. Michael Livner, MD, director of mammography at X-Ray Associates of New Mexico in Albuquerque, gives referring physicians a pad of order forms listing every breast procedure and breast problem and providing a diagram on which the site of a problem can be indicated. The physician simply checks the appropriate items on the lists and signs the form. Accurate clinical diagnoses and service requests are essential, as discrepancies between what is ordered and what is delivered make delays in payment or denials of payment more likely.

Poller’s department has been working to educate physicians who bring in films for review about the need to include the patient’s insurance information. “That way, you can send a bill for the consult. You may not get paid, but if you don’t send a bill, you certainly won’t get paid,” he said.

Mammographers can help reduce medical costs overall by educating clinicians on the Breast Imaging Reporting and Data System (BI-RADS) terminology mandated by the MQSA. A study by Stacy Vitiello, MD, and associates in the Department of Diagnostic Radiology at Yale University demonstrated that many clinicians are not familiar with BI-RADS and its interpretation and, as a result, are making many inappropriate referrals. In a paper presented in May 2000 at the American Roentgen Ray Society meeting, Vitiello noted that 47% of the respondents were not aware that BI-RADS was required, and 64% had received no education in it. Only 57% of the clinicians were aware that the likelihood of breast cancer being present in a woman with a BI-RADS 3 assessment was less than 2%, and only 51% knew that a BI-RADS 5 rating indicated a 90% likelihood of cancer. More than 60% of the clinicians sent a patient for further studies when assessment of a patient was BI-RADS 3, where radiologic follow-up is considered the appropriate course.

Know the Codes, Use Them Wisely

“The game plan for most reimbursement is to delay and deny payment,” Livner pointed out at the Breast Imaging Conference in New Orleans in October 2000. “Your goal is to prevent the denial” by understanding coding systems and rules.

Poller expressed it this way: “Coding starts with scheduling and ends with the billing office.”

The reimbursement for most procedures on outpatients being seen at hospital-based clinics recently changed. The new system is the Hospital Outpatient Payment System (HOPPS), which is based on the Ambulatory Payment Classification (APC), analogous to Diagnosis-Related Groups. The intent of the new system is to “encourage more efficient delivery of care” and to reduce patient copayments. The codes for breast procedures are listed in Table 1 (page 24); these sums do not include physician payments. Procedures at freestanding breast imaging centers and other facilities not affiliated with hospitals are not covered by HOPPS/APC. Likewise, screening mammography is not covered; reimbursement for screening mammography is defined by law.

“The coding and changes in coding are labyrinthine, and as you start to delve into them, you realize there is no bottom,” said Mendelson. “But we must begin to understand them.”

Each breast imaging center should keep a list of ICD-9 (International Classification of Diseases-Ninth Edition), CPT (Current Procedural Terminology), and HCPCS (HCFA Common Procedure Coding System) used in its geographic region and keep it updated. Poller recommended having one person in each practice be in charge of coding practices and noted that any mammogram for a patient with a history of breast cancer is a diagnostic study. Mendelson stressed that residents and fellows should learn the codes as a mandatory part of their training.

Several temptations must be resisted if a mammography center does not want to be on the Medicare “hit list” or given an “adverse profile” by third-party payors. Inappropriate upcoding and rebilling of patients should not be done. Trouble also follows if the report of the study and the billing contain different information. For example, if a screening examination has been ordered, the bill should not indicate that a diagnostic examination was performed even if such an examination was appropriate for the patient. Appropriate education of referring physicians, as discussed above, may help avoid this difficulty.

Multiple codes should be used when appropriate. Logan-Young remarked that many patients ask her about hormone-replacement therapy, and if the discussion is not related to the procedure being performed, a separate bill can be submitted for the consultation.

Conduct Regular Audits

Each mammography center should regularly conduct at least two types of audits. One is an audit of billing practices. At regular intervals, perhaps monthly, some percentage of the recent procedure records are examined to make certain the coding was correct. The intent is to identify mistakes that can cost the center money, such as billing for a screening rather than a diagnostic mammogram in a patient referred for evaluation of a breast problem.

The other type of audit is of the quality of the work and its cost implications. X-Ray Associates performed a 7-year audit of its mammography work and demonstrated to third-party payors that it was saving them money by catching more breast cancers at an early stage, when treatment was less costly. The Wende Breast Clinic does further diagnostic studies on women with an abnormality on a mammogram before referring her to a surgeon. As a result, even before it began doing core biopsies, the number of surgical biopsies per cancer found was 1.5 for its patients versus 4.0 for the rest of the city.

“When we added in the cost of our biopsies and subtracted that from the cost of surgery, we found that we saved the HMOs $1.2 million a year,” Logan-Young said.2

The point, as expressed by Livner, is to “[s]how the HMO that you are saving them money because that’s all they care about.”

Be Prepared to Fight

Logan-Young stressed the importance of being prepared to fight with HMOs.

“About 65% of patients in Rochester are covered by HMOs. We were able to persuade the largest one, which was 45% of our reimbursements, that we were saving them money with our thorough workups. However, the other HMO would not reimburse us, so we dropped out of their network and ran an ad in the newspaper explaining why we had done so. The dropout was not a big loss, as we were losing money on every one of their patients.”

Logan-Young also noted that Medicare regulations can help in dealing with HMOs. “If you find a problem in a screening patient, she can be converted to a diagnostic case under Medicare,” she pointed out. “You do not have to send her home to come back another time. So tell the HMOs, if they don’t agree, ‘We’re dropping out of your program because you will not give us what Medicare does.'”

Poller stressed the importance of marketing, a message that appears to have been heard by many practices, as approximately 10% of the people in the audience at the RSNA session were marketing managers for their practices.

Just as important as attracting patients is keeping them. Logan-Young noted that patients usually want answers even if they have to wait for a while to get them. Her goal is to be able to give the patient a definitive answer before she leaves the clinic. Not only can readings by two mammographers usually be obtained within a little more than an hour for screening studies, but the clinic can often complete the workup of a diagnostic case the day the patient comes in.

Comprehensive Centers

“It is my philosophy that we are the gatekeepers of breast disease,” Poller said. “We should all be able to direct a workup so we can keep the care of the patient in our facility.” Comprehensive diagnostic facilities also can make mammography profitable. A study at the University of South Carolina, reported at the RSNA in 1999, found that the facility’s 41% increase in screening mammograms and 25% increase in diagnostic mammograms produced a 196% increase in the RVUs for follow-up procedures.

Mammographers and breast centers are faced with a tremendous challenge as this century gets under way.? “Medicare rewards mediocrity,” Livner noted. “But mammography works only if it is of high quality.”

Other Reading

Logan-Young W. The breast imaging center: successful management in today’s environment. Radiol Clin North Am. 2000;38: 853-860.

Judith Gunn Bronson, MS, is a contributing writer for Decisions in Axis Imaging News.


  1. Martinez B. As more women seek mammograms, many have to wait months. Wall Street Journal. 2000;236(84):A1, A17.
  2. Logan-Young W, Dawson AE, Wilbur DC, et al. The cost effectiveness of fine-needle aspiration cytology and 14-gauge needle biopsy compared with open-surgical biopsy in the diagnosis of breast carcinoma. Cancer. 1998;82:1867?1873.