Who Pays the Bill For a Second Opinion?


Even though he does not remember much, Zack Dunlap will never forget the day he died. That may sound strange, except for the fact the 21-year old Oklahoman is now alive and well, saying he feels “pretty good” almost two months after an ATV accident rendered him temporarily brain dead. As his family members paid their last respects before doctors prepared to procure Dunlap’s vital organs for donation, a strange thing happened. Dunlap started to respond to stimulus, moving his foot and hand. Five days later he opened his eyes, and after an additional 48 days of hospital rehabilitation, he finally returned home. Some might call it malpractice, but for Zack's parents Pam and Doug Dunlap, it is a miracle. “There’s no blame in a miracle,” Pam said upon her son’s return from death. “And there never will be for us.” 

Be it a miracle or medical error, clearly Dunlap could’ve benefited from a second opinion. When should you get one? And if you do ask to consult with an additional medical professional, who foots the bill? According to a survey conducted by Harris Interactive (HPOL) for the PBS health series Second Opinion, more than a third of U.S. adults never seek a second opinion, and almost one in ten rarely or never understand their diagnosis. Getting a second opinion means consulting with another doctor to either confirm a diagnosis or weigh in on suggested courses of treatment. It’s recommended to try and get a second opinion before a treatment plan has already been established to avoid delaying your recovery. 

According to the National Brain Tumor Foundation, the cost of a second opinion can vary greatly depending on your health insurance policy. “In general, health plans do pay for second opinions,” says Robert Zirkelbach of America’s Health Insurance Plans, a health insurance company lobbying group. “But it is always important consumers consult their personal health plan to find out what it covers." Most health insurance plans will pay for at least a percentage of the cost to get a second opinion, assuming it’s considered medically necessary. Medicare will pay 80% of the cost, and if the second opinion doesn’t agree with the first, it will pay 80% of the cost to get a third opinion. If you are part of a Medicare Health Maintenance Organization (HMO) you are entitled to a second opinion under your benefits, but some plans require a referral from your primary care physician. And just like other treatment under your HMO, you are only covered when you see an in-network physician. 

Call your insurance provider before getting a second opinion to prevent any surprises on your bill. In addition to finding out whether you can see an out-of-network physician, or need another doctor’s referral, it is also important to find out what laboratory procedures are covered. Diagnostic tests can be costly–an MRI can cost up to $4,000–and some insurance providers won’t pay for repeat tests. Kaiser Permanente limits coverage to physician consultation and new X-rays and laboratory tests, so if a doctor orders repeat tests, guess who gets slapped with the bill? (You do.) Be aware of this when seeking your second opinion and come prepared with all of your previous diagnostic materials. While medical miracles have been known to happen—just ask Zack Dunlap—a miracle medical bill payment is a lot less likely.


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