When to Ask Medicare for a Second Opinion

No one wants to take chances with their health but that is what you might be doing if you make major medical decisions without seeing what is behind door number two. Do you know your rights when it comes to getting a second opinion?

Why You Might Need a Second Opinion

Doctors may have years of training but they are only human. That means they make mistakes. Diagnostic errors happen in the outpatient setting 5% of the time, affecting as many as 12 million people each year. In the hospital, diagnostic errors are even more common. Getting a second opinion could decrease the odds that a diagnosis is wrong or missed altogether.

A 2017 study at the Mayo Clinic found that people who seek a second opinion will get a different diagnosis the majority of the time. While 66% of people get a more fine-tuned diagnosis as many as 21% get a new diagnosis altogether.

A 2018 study that focused on breast cancer patients found that seeking a second opinion changed the diagnosis for 43% of the study participants. Second opinions that result in diagnostic changes may affect cancer prognoses as well as treatment plans.

What a Second Opinion Involves

Medicare will pay for a second opinion when you are facing a medical surgery or a major therapeutic procedure. This does not mean the evaluation is free. You are still subjected to the 20% Medicare Part B coinsurance you would pay for any other outpatient medical care.

Specifically, Medicare will pay for a board-certified physician to review any existing data in regards to the medical condition in question. Additional information may also be sought, including a physical examination and, in some cases, additional tests.

A thorough second opinion evaluation will review your medical information, confirm the accuracy of a diagnosis, establish a prognosis, and review available treatment options whenever possible. This may or may not involve multiple providers. For example, a pathologist may review a biopsy specimen to verify a diagnosis while a surgeon may discuss different treatment approaches for that condition.

For clarification, a second opinion refers to evaluation by a doctor in the same field of medicine. A family physician referring you to an oncologist, for example, is not considered a second opinion. Consultation with a second oncologist for the same medical problem, however, would be.

What Medicare Will and Will Not Cover

Medicare will pay for a second opinion and sometimes a third if the first and second opinions do not agree. Think of it as a tiebreaker.

What Medicare will not do is tell you which provider to pick in the end game. The final decision is yours to make. You can go back to the original provider or continue care with the second opinion provider.

If you choose to pursue surgery, Medicare will then decide whether or not to cover it. That's right. Just because one, two, or three doctors recommend a procedure does not mean that Medicare will pay for it. Medicare requires that a procedure be medically necessary according to their standards. Of note, Medicare does not cover cosmetic surgery or procedures it considers to be experimental for this reason.

Medicare often does not pay for repeat testing either. For example, if Ms. Jones had a mammogram, that same mammogram will need to be reviewed by the new consultant. Medicare may not see the medical need to repeat the mammogram for the new doctor to make a decision. Studies not previously ordered in the original evaluation, however, may be covered if Medicare sees them as appropriate.

Deciding What to Do

Surgery is not something to be taken lightly. There could be complications and of course, there will be downtime required for recovery. You need to be comfortable that you are making the best decision for you. The same goes for any other medical tests or treatments that are recommended to you.

For these reasons, you should not be anxious about approaching your doctor with a request for a second opinion. To make educated choices about your health, you may need more information or reassurance regarding your medical options. Discuss any concerns you have with your doctor and request he forward all records for review to the new consultant.

To prevent bias, it is preferable to seek a second opinion outside of your provider's health system. Picking someone from the same office or hospital group, for example, may lead to a conflict of interest. As always, be sure that the provider you choose accepts Medicare or you will be left to pay for everything out-of-pocket. Better yet, if the doctor agrees to the Medicare physician fee schedule, you can keep costs down by avoiding limiting fees.

The guidelines for second opinions may differ if you are on a Medicare Advantage plan as opposed to Original Medicare. This is because Medicare Advantage plans are run by private insurers, not the federal government. If you are on a Medicare Advantage plan, seeking out-of-network specialists for a second opinion could cost you more, especially if you decide to continue care with that provider afterward.

A Word from VeryWell

Not every condition will require a second opinion. That said, if you are faced with a diagnosis that has a poor prognosis or one that has more complicated or costly treatment options, you may want to consider getting another evaluation to make sure you have all the information you need to make a decision on how to proceed. Medicare will support you as you get checked out.