Second Opinions 101

Most health insurance pays for a second, in-person, medical opinion.

• It generally doesn't matter where the doctor is located. 
• There may be steps you have to take before requesting an opinion in order to have a second opinion covered. 
• Many insurance policies, including Medicare, require that the patient actually be seen by the doctor. They do not pay for online second opinions or opinions where a doctor just reviews a medical file.

If You Have Health Insurance

If you have medical insurance you are probably covered for the cost of a second opinion, and in some cases a third opinion. In fact many plans require a second opinion before agreeing to pay for major or expensive treatments. Some states even have laws requiring insurance coverage for a second opinion.

Always check the provisions of your policy before obtaining a second opinion. Even if second opinions are covered, there may be details or conditions of which you should be aware. For example, many policies do not cover when patient and doctor do not meet face-to-face.

To learn more, read the following information with respect to the type of insurance you have:

• Indemnity (fee-for-service) Insurance Coverage: 
  • There are generally no restrictions in obtaining a second opinion. You can see the doctor of your choice. Your out of pocket expense will be based on the provisions of your plan.
  • Consider asking the doctor if he or she will accept "assignment" of your insurance as payment in full. Many doctors are willing to do so upon request, particularly if payment would present an undue hardship for you.
  • To learn more, see Indemnity Health Insurance Policies.
• Health Maintenance Organizations (HMO's)
  • Most HMO's provide for second opinions at no cost to the insured - with the possible exception of a small co-pay.
  • A referral from your primary care doctor is usually required.
  • It is usually difficult to obtain coverage for a second opinion or treatment outside of your medical group or network plan. If you and/or your doctor feel that this is necessary, be prepared to do battle with your insurance provider. See Health Insurance: Claims: Appeals: Sample Letter: Second Opinion.
  • To learn more, see HMOs.
• Preferred Provider Organizations (PPOs)
  • Most PPO's cover the cost of second opinions at no charge to the insured - with the possible exception of a minimum co-pay, provided you are seen or treated by one of the doctors from the plans "preferred providers" list.
  • Unlike true HMO plans, PPO doctors usually practice in different offices and are affiliated with different hospitals. Therefore, it may be much easier to obtain a true "objective" second opinion.
  • A referral from your primary care doctor may not be necessary if you choose a doctor associated with your plan network. However, if you see a doctor or receive treatment at a facility that is outside of the network, you will be responsible for a co-pay, which can be very expensive.
  • To learn more, see Preferred Provider Organizations (PPOs).
• Medicare Coverage
  • Traditional Medicare
    • Medicare Part B covers visits to doctors.
    • Medicare pays 80% percent of the approved amount for a second opinion. Your share is usually 20 % of the Medicare approved amount, after you have paid your $100 annual Part B deductible.
    • If the second opinion does not agree with the first, Medicare pays 80% of the approved amount for a third opinion.
  • Medicare Managed Care Plan
    • Medicare managed care plans (such as HMO's), provide the right to a second opinion from doctors within the plan. Most plans will only pay for a second opinion if you first get a written referral from your primary care doctor.
    • If you want to get a second opinion from a doctor who does not belong to your plan, speak to your plan first. According to Medicare, a few plans may pay for a doctor outside of your plan, but most will not.
  • Private Fee-for-Service Plan
    • If you are in this type of plan, Medicare will pay for a second opinion.
    • If the first two opinions differ, the Private Fee-for-Service plan will pay for a third opinion.
  • To learn more, see Medicare.

If you have to pay for the opinion yourself

If you have to pay, whether because your insurer balks at paying or you are not insured, see if you can negotiate a lower rate for the opinion. Let the doctor's office manager know that you have to pay for the opinion yourself. If the doctor doesn't negotiate individual fees, ask if you can make payment arrangements, such as monthly installments. If you don't get satisfaction from the office manager, see if you can speak with the doctor directly. Staff not have the authority to make such decisions.

If you can't afford a second opinion, many specialists will give an opinion for free if they don't have to take the time to see the patient or review an entire medical record.

• It's easy to find out how to contact a doctor these days. Doctor searches usually give you contact information. If not, you can usually get an idea of the institutions with which the doctor is affiliated. You can then find out how to contact the doctor through the institution's web site.

• Ask your doctor to summarize the facts of your situation and give you a copy of the relevant tests or reports. You can then e-mail or overnight this information to the specialist with a request for an opinion.

If you pay for an opinion, you can still go after your insurance company for reimbursement. See Appealing A Denial Of A Request For A Second Opinion.

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