Does Medicare Pay For Second Opinions Before Surgery?
Medicare will cover the cost of getting a second opinion on surgery in certain cases. It will also help you pay for a third opinion if the first and second are in conflict. You will still be responsible for some out-of-pocket costs for the second and third opinion.
Does Medicare Cover Second Opinions?
Medicare Part B medical insurance will pay most of the cost for a second opinion in some cases. But there are certain criteria that have to be met.
- You must be enrolled in Medicare Part B.
- The doctor giving the second opinion must accept Medicare.
- The surgery or other treatment must be medically necessary.
- It must not be emergency surgery.
Medicare will also cover its portion of the costs for additional tests the second doctor orders and any other services that are medically necessary.
If the first and second opinions are different, Medicare will also pay most of the costs for a third opinion.
If both opinions are the same, Medicare will sometimes still pay for a third doctor to make a confirmatory consultation. But the doctor will have to submit the claim properly, and Medicare has to determine that the doctor’s services were necessary and reasonable.
Medicare does not cover surgeries or other procedures, such as cosmetic surgery, that are not medically necessary. It also will not pay for second opinions for procedures that are not medically necessary.
Medicare Advantage plans may have different rules or coverage for second and third opinions. Check with your plan’s administrator to determine specifics before seeking a second opinion.
What’s 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 (Medicare Supplement) 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 it’s important to contact your plan’s administrator to find out exactly what is covered if you seek a second opinion.
When Should You Consider a Second Opinion?
When a doctor tells you that you have a health condition that requires surgery — and it’s 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.
- 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.
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. It’s best to choose a doctor from a different office or practice.
Once you’ve scheduled your second opinion appointment, you’ll need to make certain arrangements. This will make it easier and quicker for you to get your second opinion.
- Ask your first doctor to forward your medical records to the second doctor to prevent duplicating any tests or other exams.
- Call the second doctor to make sure they have your records.
- 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 plan’s network. If you go to a provider who is out of your plan’s network, you may have to pay more. Check with your plan’s administrator to determine what your plan requires.
4 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2020, September). Getting a Second Opinion Before Surgery. Retrieved from https://www.medicare.gov/Pubs/pdf/02173-Getting-a-Second-Opinion-Before-Surgery.pdf
- WebMD. (2019, September 17). Second Opinions. Retrieved from https://www.webmd.com/health-insurance/second-opinions
- Miller, J.T. (2017, December 6). How Medicare Handles Second Medical Opinions. Retrieved from https://www.huffpost.com/entry/how-medicare-handles-seco_b_10654850
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Second Surgical Opinions. Retrieved from https://www.medicare.gov/coverage/second-surgical-opinions