Thursday, November 17, 2022

Does Medicare Pay For 2nd Opinions

Don't Miss

How Much Do Second Opinions Cost

Medicare For All: What Does it Actually Mean?

Your costs will depend on the part of Medicare youre using and whether youve already paid any deductible associated with your plan. Some costs you might see include the following:

  • When you use original Medicare. Youll need to meet your deductible before Medicare will start to cover your costs. The deductible in 2020 is $198. After you meet it, youll pay 20 percent of the cost of your appointment.
  • When you use Medicare Advantage. Medicare Advantage plans have their own prices and costs. Check the details of your plan to see if you have a deductible and what your copayment or coinsurance amount is.
  • When you use Medigap. Your costs with Medigap will depend on your plan. Some Medicare plans include coverage for the Part B deductible, while others include coverage only for your coinsurance payments.

Medicare will cover your second opinion as long as its about a service that Medicare covers. Medicare will cover most services, but there are a few it never covers. These services include:

Medicare wont provide coverage if you need a second opinion about one of the services listed above. However, as long as your service is something Medicare does cover, you can get a second opinion with Medicare.

If youre not sure whether a service is covered, you can search for it on the Medicare website.

When Should You Consider A Second Opinion

When a doctor tells you that you have a health condition that requires surgery and its not an emergency you may want to consider a second opinion. A second opinion can help you make a better-informed decision about how to treat your health problem.

Your rights when seeking medical treatment include:

  • The right to know and understand your choices for treatment
  • The right to have another doctor review those choices with you a second opinion
  • The right to participate in decisions on your treatment by making your wishes known

If you need emergency surgery for an aneurysm, blood clots, acute appendicitis, injuries from an accident or any other life-threatening emergency you should not wait for a second opinion.

Can A Provider Deny Your Request For A Second Opinion

Yes, a provider can turn you down, but this is very unlikely. Most healthcare providers today understand your right to a second opinion per the American Medical Associations Code of Ethics. But if you dont need their referral, you can still seek a second opinion.

If you do need their referral, talk to your insurance provider about the situation. They may tell you to go ahead and get the second opinion without the referral. They may also call your provider and ask for the referral.

Don’t Miss: What Is Medicare Plus Blue

Getting A Second Opinion

When you get a second opinion, its a good idea to arrive with all the necessary information you would need for the second doctor. Be sure your first doctor has sent over all of your medical records, and =put together a list of questions you may have for the second doctor.

During your visit, the second doctor will examine you and review your medical records. Keep in mind, they may order different tests from what the first doctor ordered. In these instances, Medicare will cover the costs of any additional testing you may need.

In some cases, the second doctor will come to the same conclusion as the first doctor. In this case, you can continue with the recommended treatments.

In other cases, the second doctor may give you a different diagnosis or treatment recommendation. Depending on what the second doctor says, you have a few options:

  • You can choose to receive treatment from the second doctor.
  • You can go back to the first doctor and discuss what the second doctor said.
  • You can opt to receive a third opinion from another doctor.

If you decide to opt for a third opinion, Medicare provides the same coverage as if you were getting a second opinion.

Why You Might Need A Second Opinion

Will Medicare Cover A Second Opinion before Surgery?

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.

You May Like: Does Medicare Pay For Glucometer

Physician Participation In Second Opinion Programs

To implement and operate a successful SSOP, it is necessary to recruit a sufficient number of physicians to ensure that beneficiaries have reasonably convenient access to consultants appropriate to their conditions. This section discusses the demonstration experience and the reimbursement and other factors which affect physician participation. The demonstration experience indicates that sufficient numbers of surgeons in most specialties were recruited.

At the beginning of the New York demonstration, Blue Cross and Blue Shield of Greater New York’s subscriber second opinion program, Program for Elective Surgical Second Opinion , had already recruited some 2,000 board-certified surgeons to its SSOP consultant panel from among 6,000 area surgeons who had been invited to participate. The principal reasons given for refusal to participate in the private SSOP were the following :

  • The reimbursement fee was inadequate.
  • The forms were time consuming to complete.
  • The terms of the agreement were confining, particularly as they related to the surgeon being required not to treat the patient or perform surgery.
  • The concept perhaps was not one that they wished to support.

The New York Medicare demonstration recruited 1,900 of the 2,000 physicians already participating in PRESSO. Only two subsequently withdrew from the Medicare demonstration in its first two years, citing inadequate reimbursement as the reason .

How Do You Prepare For A Second Opinion Appointment

Being prepared for a second opinion appointment is important. After all, youre meeting with a provider who doesnt know you, your medical history, or your current diagnosis. Make sure you tell their office that youre coming in for a second opinion and ask what medical records you should deliver to them in advance.

Also, bring a folder with the following items to your visit, if you have them:

  • Test or biopsy results

  • Surgery reports or a discharge plan if you were in the hospital

  • Your current providers treatment plan

  • A list of your prescriptions and over-the-counter medications

  • A list of questions

You May Like: Does Medicare Pay For Someone To Sit With Elderly

When Is A Second Opinion Helpful

For everyday health care, you probably don’t need a second opinion. But a second opinion may be a good idea if:

  • You are deciding about a costly or risky test or treatment, like a surgery.
  • You are not clear about how well a test or treatment may work.
  • You need more information about your options.
  • You are unsure about a diagnosis.

Savvy Senior: How Medicare Handles Second Medical Opinions

2017 Sep 7th, Medicare Advantage & Prescription Drug Plan Fall Conference (Afternoon Session)

DEAR SAVVY SENIOR: Does Medicare cover second medical opinions? The doctor I currently see thinks I need back surgery, but I would like to get some other treatment options before I proceed. What can you tell me?

Searching Senior

DEAR SEARCHING: Getting a second medical opinion from another doctor is a smart idea that may offer you a fresh perspective and additional options for treating your back condition so you can make a more informed decision. Or, if the second doctor agrees with your current one, it can give you some reassurance.

Yes, Medicare does pay for second opinions if your current doctor has recommended surgery, or some other major diagnostic or therapeutic procedure.

If you’re enrolled in original Medicare, 80 percent of the costs for second medical opinions are covered under Part B , and you don’t need an order or referral from your doctor to get one. Medicare will even pay 80 percent for a third opinion, if the first two differ.

Most Medicare Advantage plans cover second opinions too, but you may need to follow certain steps to get it paid for. For example, some plans will only help pay for a second opinion if you have a referral from your primary care doctor, and/or they may require that you can only use a doctor in their network. If you have a Medicare Advantage plan, you’ll need to call it to find out their rules.

Finding another doctor

Read Also: What Urgent Care Takes Medicare

How Do You Use A Second Opinion

When you have gathered the information you need, go over it with your primary care doctor or the specialist of your choice. Talk about how treatment choices might change your daily life, now and in the future. For testing choices, talk about how the results would be useful to you.

If your doctors agree, your decision should be clearer. But sometimes doctors disagree. Even when doctors follow the same guidelines, there may be more than one treatment choice. Two doctors may have good, yet different, opinions about how to treat you.

If the doctors don’t agree, talk to your primary care doctor again. Can he or she help you with your decision? If not, and if you still wonder about other options, talk to a different kind of provider. For example, if you are thinking about back surgery, meet with two surgeons and talk to a physical therapist, a physiatrist , or a doctor with experience in nonsurgical back care. You might learn about some nonsurgical, lower-risk choices you can try.

Remember, the final choice is yours.

Medicare Second Surgical Opinion Programs: The Effect Of Waiving Cost

This report was prepared pursuant to Section 958 of the Omnibus Reconciliation Act of 1980, Public Law 96-499, which examines the desirability of waiving present Medicare cost-sharing requirements for second surgical opinions. It is based on current results from the Department’s comprehensive evaluation of second surgical opinion programs being conducted by Abt Associates, Inc., and on additional analyses conducted by the author.1

The findings presented in this report indicate that waiving cost-sharing as an incentive for Medicare beneficiaries to voluntarily obtain second opinions does not appear to result in extensive use of the benefit. Voluntary second opinion program users are a select group of beneficiaries actively seeking health care information. These beneficiaries decided that unquestioned compliance with surgical recommendations may not be in their best interest. As measured by the demonstrations, relatively few Medicare beneficiaries currently seek second opinions.

There has been considerable interest in the past five years regarding the appropriate use of surgical services. The Subcommittee on Oversight and Investigations of the House Committee on Interstate and Foreign Commerce published a report entitled Cost and Quality of Health Care: Unnecessary Surgery in January 1976. The report observed the following:

The SSOPs conduct publicity campaigns promoting the second opinion benefit.

Read Also: Will Medicare Pay For Cialis

Whats Your Cost For A Second Opinion Under Medicare

You are responsible for your Medicare Part B deductible and 20 percent of the Medicare-approved cost of the second opinion.

The same out-of-pocket costs apply if you are eligible to seek a third opinion.

A Medigap insurance plan may cover some of your out-of-pocket costs for a second opinion including a portion of your deductible, coinsurance and any copayment.

Medicare Advantage plans are required to cover anything Medicare Part A and Part B covers, but your plan may provide additional coverage or benefits when seeking a second opinion.

Medicare Advantage and Medigap plans are sold by private insurers. Coverage and benefits vary from plan to plan so its important to contact your plans administrator to find out exactly what is covered if you seek a second opinion.

Does Medicare Advantage Cover Second Opinions

Thereâs Still Time for a Second Opinion on Your 2020 Medicare Coverage ...

While Medicare Advantage must cover everything that Medicare covers, it can vary in how it covers it. Plus, since most Medicare Advantage plans are HMOs, you may have to be approved by your primary care physician before seeking a second opinion from a specialist.

For further questions call a Senior65 agent at 800-930-7956.

Related Articles:
  • Pros and Cons of Medicare Advantage Finding the right Medicare insurance can be rather confusing for seniors – especially when parsing through the 150-page “Medicare and You” booklet that the government sends out as you approach age 65. We have made a list of the advantages and disadvantages of choosing a MA plan that should help
  • Medicare Part D Drug Overview If you are already familiar with how Medicare works, you know that it does not cover prescription drugs. Throughout this article we will explain how to get this sorted out easily.
  • Medicare Insurance Switching: Ultimate Guide With so many different plans, carriers, deductibles and what not, picking the wrong plan happens. A lot. Check out your options.

Also Check: What Is Medicare Part B Reimbursement

Why Seek A Second Opinion

Perhaps youre not feeling confident about your doctors decisions. Maybe youre feeling rushed. Other reasons to get a second opinion include:

  • Your insurance company may require it before covering your treatment.
  • You may have options including not needing the medicine or procedure, or one being less expensive than another.
  • Youre concerned about the risk or how it might affect your lifestyle, family or work.

What To Say To Your Current Doctor

First, ask your doctor questions about your condition so that you understand whatâs happening. Sometimes you might feel uneasy because you need more information, so donât be afraid to ask more than once. If you need more time than your doctor usually gives you, ask the receptionist to help you schedule a longer appointment.â

Your doctor knows that getting other professional opinions is a good practice and that you have a right to be informed of your options. They will likely support a second opinion, so itâs best to ask for it outright. Some examples of questions you can ask are:

  • If you had this condition, is there another doctor youâd want to talk to about your options? Will you refer me?
  • Iâd like to see another doctor to cover my bases. Who would you recommend?
  • Iâd like to get a second opinion. Would you refer me to a specialist?
  • Before starting treatment, Iâd like to get another opinion. Would you help me?â

You will need to ask for a copy of your medical records, including your doctorâs proposed treatment plan. By law, your doctor must give you a copy, but they might charge a fee. Sometimes you can ask to have them transferred directly to another doctorâs office, which might also cost a fee.

Also Check: Will Medicare Cover Lasik Surgery

Am I Putting My Relationship With My Current Doctor At Risk

Rest assured that getting second opinions is a simple, routine part of medicine. In fact, your physician may also be seeking one or more additional opinions. Doctors ask their colleagues for curbside consults all the time, Varma explains. Sometimes a fresh pair of eyes and a new perspective help if you’ve had a long-standing relationship with a patient.”

It’s not uncommon, however, for patients to forgo a second opinion for fear of insulting their physician. Set that notion aside. You are in charge of your health one particular doctor is not. Many patients think that seeking a second opinion somehow indicates a lack of trust, rather than a desire to confirm what their doctor has told them and explore options their doctor either might not have access to or be aware of, Linden observes.

What Do I Do To Seek A Second Opinion

Warren ditches ‘medicare-for-all’, gives voters the choice to opt-in

Before you visit a second doctor, have your records forwarded to him or her. Better yet, get a full set and bring them with you.

Also, be sure to come with specific questions. The more specific your questions, the more focused your meeting, the better the second opinion will be, says Stein, who is also a volunteer for the American Heart Association.

You should also bring a pad and pen to write down important things, and consider having a significant other to sit and listen .

When youre done, ask the second doctor to send his notes to you and your doctor.

Read Also: Does Medicare Pay For Assistance At Home

How To Find A Doctor For A Second Opinion Under Medicare

Before scheduling an appointment for a second opinion, be sure the doctor accepts Medicare. Medicare can help you find a doctor for a second opinion.

You can also ask your first doctor or another doctor you trust to recommend another doctor who can give you a second opinion. Its best to choose a doctor from a different office or practice.

Once youve scheduled your second opinion appointment, youll need to make certain arrangements. This will make it easier and quicker for you to get your second opinion.

Steps to Take Before Your Second Appointment

  • Ask your first doctor to forward your medical records to the second doctor to prevent duplicating any tests or other exams.
  • Confirm with the second doctor that he or she accepts Medicare.
  • Prepare a list of questions and concerns you may have to discuss with the second doctor.
  • Have a relative or friend accompany you to the appointment.
  • If you have a Medicare Advantage plan, you may have to get your second opinion from a doctor in your plans network. If you go to a provider who is out of your plans network, you may have to pay more. Check with your plans administrator to determine what your plan requires.

    More articles

    Popular Articles