Adjustment Code 61: Penalty for failure to obtain second surgical opinion

Adjustment Code 61: Penalty for failure to obtain second surgical opinion


Most health insurance plans will pay for a second surgical opinion, but be sure to contact your plan beforehand to find out for sure. In some cases, if you don’t get a second opinion for a procedure, you may have to pay a higher percentage of the cost.

When your healthcare provider recommends surgery or a major procedure or treatment, it’s smart to get a second opinion from another expert. But, how do you know a second opinion is in order? And how do you go about getting one? Here are some answers to these and other important questions.

What Is a Second Opinion?

A second opinion means that you choose to see another doctor or specialist after you’ve received an initial diagnosis or treatment plan for a medical condition. The second doctor reviews your medical history and gives their interpretation of your health. They will give you their view on your diagnosis or treatment plan. They may suggest different treatment options than the first doctor you saw.

Your doctor is usually comfortable with your decision to get a second opinion. Getting a second opinion is a good idea when you have a medical issue. In fact, you might find that your general doctor will refer you to a specialist or encourage you to see another doctor before you even ask.

When should you get a second opinion?

Don’t waste time checking out choices if you need emergency treatment. But if your healthcare provider suggests nonemergency surgery or a major medical test, it can be worthwhile to get a second opinion for any of the following reasons:

  • Your health insurance requires a second opinion.
  • Your diagnosis isn’t clear.
  • You have a lot of medical conditions.
  • The treatment offered is experimental, controversial, or risky.
  • You have a rare condition.
  • You have a life-threatening condition.
  • You have many treatments to choose from.
  • You’re not responding to treatment.
  • You feel like you can’t talk to your current doctor.
  • Your doctor says they can’t help you or won’t treat you.
  • Your doctor doesn’t specialize in your condition.
  • You want peace of mind.

Just feeling uncertain about having surgery or a major procedure may be reason enough. After all, no one healthcare provider knows everything about all conditions, or about all the new breakthroughs in treatment being reported.

Where to start?

If you choose to go for a second opinion, it’s a good rule to ask someone with at least the same level of skill and knowledge of your health condition as your current health care provider. Consider contacting a specialist. Your current healthcare provider may be able to suggest someone.

Even better, ask someone at an institution specializing in your condition, like a cancer treatment center or a heart surgery center. These centers will have the latest in healing technology, and a team of experts may be readily available to review your case.

What should you tell your healthcare provider?

Most healthcare providers will acknowledge their patients’ right to a second opinion, so you just need to be honest and straightforward.

Be sure to ask for your medical records so you can share them with the second healthcare provider. By law, your healthcare provider must give these records to you. You may have to pay a fee to have the copies made.

What should you ask the second healthcare provider?

These questions offer a good place to start:

  • Is the diagnosis correct?
  • What are my choices, and the pros and cons of each?
  • What would happen if I waited or chose no treatment?
  • What should I do with the results?

If the second healthcare provider agrees with the first, you can move forward with more confidence.

How to Get a Second Opinion?

The best place to start the process is with your general doctor. If they haven’t offered you a referral to a specialist, ask for one. If you’re already seeing a specialist, ask to see another doctor who has at least the same level of training and expertise and who isn’t their close peer.

If you feel you can’t ask your current doctor, there are other ways to get a second opinion. You can try:

  • Asking your insurance provider to recommend a specialist
  • Asking a local clinic for a recommendation
  • Asking a local hospital for a recommendation
  • Searching a medical association for a specialist near you

Also check with your insurance company to make sure your second opinion is covered and if there are any special instructions.

After Your Second Opinion

Getting a second opinion can help you make better health decisions. If the second doctor agrees with the first, you may decide to return to your first doctor and move forward with your treatment. You can also ask your doctors to work together as a team. If their opinions are different, you can use the new information to help you make the best choice for you.

What is mandatory second opinion?

The amount you must pay for health care or prescriptions before Original Medicare, your Medicare Advantage Plan, your Medicare drug plan, or your other insurance begins to pay.

Do patients have a right to a second opinion?

You have the right to receive a second opinion when you or your doctor request one. You have the right to have your doctor freely discuss your medical treatment options and care with you, without interference or restrictions by your health plan.

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