Does Medicare Cover Second Opinions?
Yes, Medicare Part B generally covers second opinions when you need medical surgery or a major therapeutic procedure. Medicare may also help shoulder the cost of a third opinion if the first and second opinions are different.
However, remember that Medicare has the right to reject treatment choices and second opinions not considered medically necessary. If you’re unsure whether a healthcare service is covered by Medicare Part B, you can search for it on the Medicare website.
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What Is a Second Opinion?
A second medical opinion is when you see a different doctor to get their view on a diagnosis or treatment. For example, you may want to seek a second opinion to determine whether knee surgery or hip replacement is truly the best option to treat your health condition.
While healthcare professionals may have years of training, diagnostic errors can still happen in the outpatient setting, which means you should not assume their word is the final say. With the number of diagnostic errors each year in the United States estimated to be at least 12 million, getting a second opinion regarding your health problems could decrease the odds that a diagnosis is wrong and even save your life.
A recent study found that patients receive significantly different diagnoses 58% of the time after getting a second opinion, resulting in major changes in their treatment plans and health outcomes.
Understand Medicare Coverage of Second Opinions
Your health problems are not something to be taken lightly. Understand how Medicare covers second opinions so you can make informed decisions about your healthcare without breaking the bank.
When to Consider a Second Opinion
Here are a few scenarios where it could make sense to seek a second opinion from a healthcare professional:
- You’re diagnosed with a serious or rare condition.
- You’re diagnosed with cancer.
- You’re not confident about the doctor’s diagnosis or disagree with it.
- Your current doctor recommends a high-risk, invasive, or experimental treatment.
- Your current treatment does not provide the expected results, or your condition worsens.
- Your current diagnosis is unclear, or you have not been provided with a definitive diagnosis.
- You’re considering surgery or have multiple treatment options to choose from.
How Second Opinions Work
If you’re enrolled in Original Medicare, you’ll use Part B to help you pay for second opinions. While not every health problem needs a second look, it can be invaluable in more severe cases such as surgery or a cancer diagnosis. To prevent bias, seek a second opinion outside of your first healthcare provider’s health system and avoid going to doctors who work in the same office or hospital group.
Ultimately, the decision of which provider to go with is yours. If the second opinion contradicts the first, a third opinion may be necessary. Just make sure the provider you choose accepts Medicare, or you could be left with a hefty out-of-pocket bill.
How Third Opinions Work
If the first two opinions about a proposed surgery or treatment plan are contradictory, Medicare Part B will also cover the cost of a third opinion from a healthcare professional. The rules will be the same as when you got your second opinion: Elective surgeries and non-Medicare covered services, such as cosmetic surgery, are not covered.
Like choosing a second opinion provider, make sure the third healthcare professional accepts Medicare and is not affiliated with the first two doctors in any way. Use the Medicare Physician Search Tool if you need help finding eligible doctors. After receiving a third opinion, the final decision is yours to make. You can go back to the original provider, continue treatment with the second opinion provider, or switch to the third one.
When Does Medicare Not Offer Second Opinions?
Medicare will not help pay for second opinions for non-serious conditions or services that it does not already cover. These could include:
- Alternative medicines
- Elective surgeries, like cosmetic surgeries
- Vision care
- Long-term care
- Dental care
How Does Medicare Advantage Cover Second Opinions?
Since Medicare Advantage Plans are required to cover everything Original Medicare covers, they’ll typically help pay for second opinions as well. However, depending on the type of Medicare Advantage Plan you have, you may need to get a referral from your primary care doctor or see a healthcare provider who’s part of your plan’s network.
Each Medicare Advantage Plan is unique and may have different regulations, so check with your plan administrator for more details on how it covers second opinions.
How Much Do Additional Opinions Cost?
On average, additional opinions from healthcare professionals can range anywhere from $900 to $2,000, depending on the complexity of your case and other factors. For example, the all-inclusive cost for a virtual second opinion for Cleveland Clinic patients in the U.S. is $1,850. This fee includes:
- Consultation with a nurse care manager
- Reinterpretation of imaging scans and lab tests
- Medical record collection
- Expert review of your case by a specialist
- Video consultation and written report from your expert
Your costs will also depend on the part of Medicare you’re using and whether you’ve already paid your deductible. If you’ve already met your Medicare Part B deductible of $226 in 2023, you’ll only pay 20% of your appointment cost. If you’re enrolled in a Medicare Advantage Plan, check your plan’s details to figure out the deductible, copayment, or <a class="wpil_keyword_link" href="https://assurance.com/health-insurance/copays-deductibles-and-coinsurance amount.
How Are Treatment Plans Established After Multiple Opinions?
After receiving a second opinion, thoroughly evaluate each diagnosis. Consider the expertise and experience of each diagnosing physician and weigh the risks and potential benefits of each proposed treatment.
If you’re still unable to decide after receiving a second opinion, or if the views of the two doctors contradict each other, consider seeking a third option. Once you do make a decision and find a healthcare provider you trust, you can work with them to create a custom treatment plan that best fits your needs.
Can Medicare Reject Your Choice of Treatment?
Yes. Even if multiple medical professionals recommend a particular procedure or treatment plan, Medicare has the final say in whether or not it will cover the costs. This means that if a service is not considered medically necessary or falls outside the realm of services already covered by Medicare, you may have to pay out of pocket for it. However, the good news is that it’s possible to appeal a Medicare rejection.
How To Appeal a Rejected Treatment Plan
If you’re enrolled in Original Medicare and are denied a treatment plan recommended by your current doctor, take the following steps to appeal the decision:
- If you’re confused about the reason for denial, call 1-800-MEDICARE for more information.
- Review your Medicare Summary Notice (MSN). It includes detailed instructions on how to start an appeal as well as the deadline for appealing.
- Fill out the Redetermination Request Form and send it to the Medicare Administrative Contractor (MAC), the company that handles claims for Medicare. Their address is listed in the “Appeals Information” section of the MSN.
- Get a decision from the MAC within 60 days after they receive your request. If the appeal is successful, your treatment plan will be covered.
- If your appeal is denied, keep appealing. Instructions for how to file your next appeal will be in the denial letter you receive.
Putting It All Together
You never want to take a chance with your health. For major procedures such as surgery or cancer treatment, getting a second or third opinion can sometimes dramatically change a treatment plan and even have life-altering consequences.
Plus, Original Medicare will typically help you shoulder the cost of getting additional opinions, so you do not have to worry about the financial burden. Before scheduling those additional appointments, however, always double-check with Medicare to confirm you’re covered.