When to Ask Medicare for a Second Opinion

Could your health be at stake?

second medical opinion
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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 extensive training but they are only human. That means they make mistakes. It is estimated that as many as 10 to 15 percent of diagnoses could be in error. Getting a second opinion could decrease the odds that a diagnosis is wrong or missed altogether.

According to a study in the European Journal of Surgical Oncology imaging (mammogram, MRI, etc.) and pathology (cytology, histology, etc.) results were in dispute for 2 percent and 3 percent of cancer cases respectively. Second opinions resulted in major changes to cancer prognosis or treatment plans 16 percent of the time.

When it comes to treatment, recommendations can differ even if everyone agrees on the diagnosis. Second opinions have been shown to change the diagnosis or treatment plan as often as 40 percent of the time. When it comes to elective surgery, for example, one study found that a third of second opinion providers found the recommended procedures to be medically unnecessary.

What a Second Opinion Involves

Medicare will pay for a second opinion when you are facing elective surgery or a major therapeutic procedure. This does not mean the evaluation is free. You are still subjected to the 20 percent 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.

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.

Generally speaking, 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.

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