Second Opinions 101

The Initial Request For A Second Opinion From A Doctor In Your Insurer's Network

If you have a managed care health policy such as an HMO or PPO type of policy, and you desire a second opinion from another doctor within the company's network or medical group, check your plan to determine the circumstances under which a second opinion will be permitted -- especially before surgery.

You may be limited to a choice of doctors or medical groups who are members of or contract with your managed care plan.

Your insurance company may also require a referral from your primary care doctor before allowing a second opinion.

If you desire to obtain an opinion from a doctor who is not in the network or medical group, it has been our experience that you will fight an uphill battle to have the insurer pay for the second opinion. The company not only has to pay the charge, but the charge is not discounted like the ones they negotiate with their own doctors. However, it is worth the effort to try to obtain the opinion from the doctor you want.

If time is of the essence, (for instance, a situation may become inoperable if it is allowed to continue), and you are denied the right to get the second opinion you want, consider obtaining the second opinion, paying for it yourself, and then appealing the decision against your insurance company,

The Initial Request For A Second Opinion From A Doctor Not In Your Insurer's Network

If you have a managed care type of policy, it is likely that you will fight an uphill battle to have the company cover the second opinion. HMOs don't like to refer members to doctors that are not part of the network because they not only have to pay the charge, but the charge is not a discounted fee like the ones they negotiated with their own doctors. However, it is worth the effort to try to obtain the opinion.

• Step 1. Determine whether the restriction against going to outside doctors for a second opinion is regulated by the medical group or the HMO.
  • Ask your doctor or your doctor's office manager. Also ask to whom you should appeal. Don't be surprised if you are told to appeal to the Referral Committee at the medical group. If such a committee exists, it is the group that is in charge of deciding when to refer patients to other doctors, and if so, to whom.
• Step 2. Confirm the next step with the HMO.
  • To avoid going down the wrong alley, call your representative at the HMO and ask to whom you should appeal the decision. The company may permit you to appeal directly to the company and override the medical group's decision. Or the company may tell you the decision can only be reviewed once the medical group has turned you down.
• Step 3. Prepare your facts.
  • Your appeal needs to present evidence with as many medical reasons as you can find that justifies the expense of the second opinion. This will require some planning and some research. Hopefully, your doctor may help. Even if she does, you may wish to search medical resources for help. Your national or local disease specific non-profit organization may have specific information that will assist with your appeal.
  • Look for an objective reason for a second opinion that a third party can understand. For example,
    • Is it the recommended treatment unusual for your diagnosis?
    • Is there a pattern of overuse of this particular procedure?
    • Are there less invasive alternative treatments?
    • Are there treatments that have had a better success rate?
    • Are there treatments that should be explored which are cheaper?
    • Is there something about your condition or the rest of your health that makes a second opinion especially important?
  • Explain why the second opinion has to be provided outside the network
    • In addition to confirming the need, you want to explain why it's important that someone render the opinion with no ties to the doctor recommending the procedure. For example, with cancer, a medical oncologist may recommend a different procedure than a surgeon.
    • As stated above, the only way to assure an independent opinion is to meet with a doctor who is not influenced by the strategies used by the HMO or the medical group.
• Step 4. Appeal.

How To Appeal Denial Of Coverage For A Second Opinion From An Out Of Network Doctor

• Explain Why A Second Opinion Should Be Provided Outside The Network
  • Explain why it's important that someone render the opinion with no ties to the doctor recommending the procedure. For example:
    • Doctors who work together or even in the same locality tend to have similar recommendations.
    • You have research that indicates there is more success with a particular procedure that no one in the network specializes in.
    • The only specialist in a procedure that has not been recommended, but seems promising, is not in the network.
• With These Thoughts In Mind Draft Your Appeal Letter
  • Start by specifically stating what you are appealing. Include what the request was, to whom it was made, who turned it down, and when.
  • Present your arguments together with any documentation you find.
  • Close by restating the specific request.
  • Get your letter to the company within the time period required by your policy for an appeal.
  • For an example of a letter appealing a request for a second opinion, click here.

Please share how this information is useful to you. 0 Comments