A mammogram is a low-dose X-ray imaging test used to examine the breast for early signs of cancer. Scheduling this preventative screening yourself, without a doctor’s referral, is now common practice at many facilities across the United States. Whether you can self-schedule depends primarily on the type of mammogram needed, your age, the time since your last screening, and the specific regulations of your state and the imaging facility.
Screening Versus Diagnostic Mammograms
Self-scheduling hinges on the distinction between a screening mammogram and a diagnostic mammogram. A screening mammogram is a routine examination performed on individuals who have no symptoms of breast disease. This exam is aimed at detecting potential issues in people at average risk, typically starting at age 40. The goal is to find cancer early, when it is most treatable.
A diagnostic mammogram is a more detailed test performed when a patient has specific symptoms, such as a palpable lump, nipple discharge, or persistent breast pain. It is also used as a follow-up to evaluate an abnormal finding from a prior screening. Because the diagnostic test investigates a specific medical concern, it almost always requires an order or referral from a healthcare provider. If you report symptoms during scheduling, the appointment will likely be changed to a diagnostic exam, requiring a referral.
Self-Scheduling Procedures and State Requirements
Self-scheduling is generally only permitted for routine screening mammograms, governed by federal, state, and facility policies. Many centers now offer online self-scheduling through patient portals, removing the need for a doctor’s visit to obtain an order. This direct access is typically available to women aged 40 and older who are due for their annual or biennial screening and are not experiencing breast symptoms.
The federal Mammography Quality Standards Act (MQSA) and the Centers for Medicare & Medicaid Services (CMS) support self-referral, stating a provider’s referral is not needed for a screening. However, state laws introduce additional requirements. While many states permit self-referral, some, like New York, still require a prescription from a qualified practitioner.
Facilities that accept self-referred patients must follow certain protocols for safety and follow-up. They are required to send the mammography report and a summary written in lay terms directly to the patient within a specified timeframe, usually 30 days. If results are abnormal, the facility must have a system to refer the patient to a healthcare provider for necessary follow-up care. When self-scheduling, be prepared to provide the name of a primary care provider to whom the results can be sent.
Understanding Insurance Coverage and Cost
The financial implications of self-scheduling are generally favorable, as the Affordable Care Act (ACA) mandates coverage for preventative services. Most private health insurance plans must cover annual screening mammograms for women aged 40 and older at 100%. This coverage must be provided without patient cost-sharing, meaning no copayment, coinsurance, or deductible applies to the screening itself. This full coverage applies whether the screening was ordered by a physician or self-scheduled, provided the facility is in-network.
The cost structure changes significantly if the screening leads to a follow-up test. If the screening detects an abnormality requiring additional imaging, such as a diagnostic mammogram, ultrasound, or biopsy, these subsequent tests are billed differently. These diagnostic follow-up procedures are typically subject to the patient’s standard cost-sharing responsibilities, including deductibles and copays.
Because the billing can be complex, contact both the imaging facility and your insurance provider beforehand to avoid unexpected charges. This ensures the facility is in-network and confirms that your plan covers the self-referred screening without cost-sharing.