Insurance Coverage for Second Opinions

Receiving a second opinion before proceeding with a particular treatment option can be a helpful step in feeling confident that you are making the right decision. It is also important to know whether your insurance will cover the second opinion consultation before searching for a provider and making an appointment.

Herein are some of the most important factors to consider when deciding to get a second opinion and making sure your decision aligns with your insurance provider's requirements.  

Medical diagnoses can be difficult to accept, particularly those that may significantly reduce the quality of your life or the amount of time you are expected to live. Even if you generally trust your doctor or other medical professionals, it is within reason to pursue a second opinion for peace of mind.

It is natural to not want to immediately take a challenging diagnosis at face value, and having another doctor evaluate your situation can help you feel more confident that you are making the right decisions about treating and managing your diagnosis.

If you are interested in getting a second opinion, you will likely need a referral from your current doctor or your primary care doctor. Your doctor’s office will prepare copies of your medical records to send to the new medical professional you are interested in seeing to make sure that he or she receives as much information about you and your medical history as possible to make the most informed diagnosis.

You will then attend a similar appointment with the new doctor or surgeon, which may be a full in-person appointment that includes new tests or simply a conversation through a virtual appointment. This doctor may be able to confirm your original doctor's diagnosis, but approximately 20 percent of second opinions conflict with your original diagnosis and may present you with a completely new diagnosis.

If the two doctors' opinions are vastly different, you may want to consider seeking a third opinion for the best chance at finding an accurate diagnosis with appropriate treatment options. While the majority of second opinions agree, at least in part, with the opinions of your original doctor, a second opinion may provide new information or an alternative perspective that can help you form a more complete understanding of what condition you have and how it should be treated. 

It is important to determine what your current insurance company's specific policies are regarding when you may be eligible to have a second opinion covered by insurance. Your insurance provider may have very specific guidelines about where you will need to get your second opinion and what types of diagnoses may be eligible for coverage. You will need to understand these requirements in advance and follow them closely to make sure you do not mistakenly obtain a second opinion that will not be covered. 

If there is a specific doctor or surgeon whom you really want to see due to their expertise, but your insurance may not cover the visit, you can consider contacting the office of the physician and requesting the pricing for an out-of-pocket visit. Ultimately, your peace of mind to see the doctor or surgeon of your choice is critical and invaluable.

Depending on your specific situation, you may be able to choose between obtaining a virtual second opinion and visiting a second doctor in person. This decision may impact the amount that you will be expected to pay if your insurance does not cover your second opinion.

In the United States, an in-person second opinion can range from a minimum of around $200 to several hundred dollars. This cost will generally vary depending on the specific diagnosis you have received, whether you anticipate new tests or are simply discussing your diagnosis with another medical professional. Many insurance companies offer coverage for second opinions.

Depending on your diagnosis, you may need to wait longer than you would like to get an appointment with a doctor you are not currently seeing. This is particularly true at busy practices and large academic centers serving a large patient population. Virtual appointments might offer more flexible scheduling options that make second opinions more practical to obtain.

Many health insurance companies will cover a second opinion, but it is important to understand exactly what will be covered and what you may be expected to pay out of pocket before committing to a second opinion.

Medicare Part B, for example, typically only covers second opinions when you are questioning whether surgery is medically necessary in your situation. Many private health insurance providers will cover a second opinion for a wider range of diagnoses and treatments, but it is important to know exactly what your plan offers before scheduling an appointment for a second opinion. 

A third opinion may be important if your first and second doctors have vastly different opinions about your diagnosis and treatment options. Generally, your insurance provider understands that you cannot make an informed decision from two significantly different or even conflicting diagnoses. In these cases, it is critical to keep in touch with your insurance company and make them aware of your situation. Insurance companies want to avoid unnecessary treatment just as much as you do. It is wise to keep them updated on your journey to an accurate diagnosis.

As always, it is important to make the most informed decisions possible, even if that requires seeking more than one opinion. Whether you are seeking care for the first time or are wanting to pursue alternative opinions, you have come to the right place. The information contained within this section will prepare you for what to expect and where to go when you need your questions answered.

• Medicare Second Opinion Coverage