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When to Seek a Second Medical Opinion

Aug. 13, 2014
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By Martine Brousse Learn more about Martine on NerdWallet’s Ask an Advisor If your situation is an emergency or if your life is at risk, do get immediate treatment. Seeking a second opinion is an option that should be considered when your immediate survival and well-being are not threatened. Provisions of the Affordable Care Act (“Obamacare”) give individuals the right to a second opinion, although insurance companies may interpret this as only for serious conditions. Restrictions may lead you to providers within a specific network or medical group. But patients should remember this option is available and recommended in several cases.

A. Your diagnosis is uncertain

Why has your diagnosis not been confirmed? If the tests results are inclusive, or if the doctor is unsure about their significance, you may want to ask another physician.

B. Your physician is inflexible

When only one treatment is offered, if you are told “this is the only way,” or if your physician refuses to discuss alternatives, it could be the time to make that other appointment. Basic online research can help you determine if a prescribed treatment, therapy or intervention is the only option. Although you should know that the Internet is filled with a lot of misinformation, too. Asking about other treatments is your right. Your doctor should explain what criteria his or her decision is based on, and why one treatment is better than another. No alternative or explanations? Get confirmation elsewhere.

C. You don’t trust the doctor or diagnosis

Many years ago, an ER doctor misdiagnosed my symptoms. Despite my strong intuition he was incorrect, I did not dare ask for another opinion, nearly costing me my life. I could have avoided surgery and lifelong side effects if I had listened to and expressed my gut feelings, and requested to be evaluated by someone else. If you feel, deep down, that what you are hearing is not right or does not make sense, seeking an outside consultation is a good idea. Trusting your physician is essential to a positive outcome.

D. Your insurance says no

Lack of coverage on your policy for the prescribed treatment or intervention may drive you to seek another physician’s opinion. Another red flag would be in the form of an insurance authorization denial, especially labeled as “not medically necessary”. While insurance companies deserve some bad press about denying prescribed services, they mostly base their determination on FDA recommendations and guidelines, scientific information and performance or outcome data. The insurance case manager can guide you through to a second opinion, appeal or external medical review process.

E. It’s not working

When the prescribed treatment is not translating into improvements, and especially if your doctor is unwilling to address or recommend a change without a good explanation, consider getting another opinion. Seek a specialist if your unresolved condition is currently managed by a general practitioner, or if you locate a medical provider more familiar with your specific diagnosis.

F. Cost is an issue

If you are self-pay, or if your policy has a high deductible or share of cost, getting another opinion may save you money in the long run. While this is less a medical second opinion than a financial one, a similar intervention or treatment may be more affordable around the corner. If you are quoted a price and have a detailed list of covered items and services, why not consult somewhere else and potentially receive the same for less?

G. Your insurance policy says so

Before any treatment, surgical intervention (even outpatient) or imaging, contact your insurance to find out if (1) an authorization is required and/or (2) if a second opinion is necessary. Some cases, mostly those considered elective, not medically necessary or experimental, require additional supporting medical documentation from another professional before they are covered.

In conclusion

Some degree of authorization is usually required before an insurance payment can be made. Contact customer service before making any appointment, especially for HMO policies. Ask for a referral outside of the medical group or office where you are currently a patient. It is quite unheard of for one physician to contradict a colleague in the same practice or group. Go up the administrative ladder if such request is denied by your insurer, or ask your state’s department of insurance for assistance. If your insurance will not cover the cost, pay cash. Negotiate on the price (generally $350 to $500 depending on the diagnosis) and forward all records before your appointment so that the time allotted is best spent going over alternatives and discussing treatment options.