When to Ask Medicare for a Second Opinion

Could your health be at stake?

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?

second medical opinion
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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% of diagnoses could be in error. Getting a second opinion could decrease the odds that a diagnosis is wrong or missed altogether.

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

When it comes to treatment, recommendations can differ even if everyone agrees on the diagnosis. In a large 2015 study, nearly 40% of treatment recommendations for study particpants changed after seeking a second opinion.

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.

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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  2. Garcia D, Spruill LS, Irshad A, Wood J, Kepecs D, Klauber-DeMore N. The value of a second opinion for breast cancer patients referred to a National Cancer Institute (NCI)-designated cancer center with a multidisciplinary breast tumor boardAnn Surg Oncol. 2018;25(10):2953–2957. doi:10.1245/s10434-018-6599-y

  3. Meyer AN, Singh H, Graber ML. Evaluation of outcomes from a national patient-initiated second-opinion program. Am J Med. 2015;128(10):1138.e25-33. doi:10.1016/j.amjmed.2015.04.020

  4. Medicare.gov. Second surgical opinions.