Q: My health insurance has only one neurosurgeon on its list. I went to him but he was not very thorough. He said I needed surgery but Im not very confident in his opinion. Do I have any other options?A: Yes, you do. Listen to your instincts if theres something about this doctor that bugs you, you dont have to be cared for by him certainly not if hes about to operate on some vital part of your anatomy. Chances are, your health plan guarantees the right to a second opinion. That's just good medical practice. If it's not in the language of your insurance plan, you can shame the plan into providing it.
The first step is to try to get your primary care doctor to refer you to a neurosurgeon outside the HMO. Most HMOs assign you to a primary care physician who decides whether you need to see a specialist. But even if you're in a less restrictive plan that lets you go to specialists without that OK, it's always best to go through the bureaucracy first. You avoid problems later. Besides, having a doctor on your side gives you added firepower with the bureaucrats.
First, check with family, friends and co-workers to see if anyone knows of a good neurosurgeon. Or check the American Board of Medical Specialties' Web site for a board-certified neurosurgeon in your community. Then, call your primary doc's office. Explain that you would like a second opinion on neurosurgery and you would like to be referred out of network. Name the doctor you've chosen or ask your primary doc's office for a referral.
If you get turned down, call the health plan directly. Tell the customer service representative that you saw the network's neurosurgeon but would like a second opinion. If you get flak, remind them that second opinions are standard, ethical medical practice it's even better if you can quote the language guaranteeing this in your coverage documents. If necessary, you can also mention that you've looked up the phone number of the state HMO regulator (this might be the Department of Insurance or Corporations find a list at the Center for Patient Advocacy's Web site, click on "insurance problems" and choose "State Insurance Commissions,") which would be interested in the fact that the plan has denied reasonable care to a member. Use that number if you continue to have problems.
If the medical procedure youre considering is urgent and you cant cut through your plans red tape quickly enough, you might consider seeing a second specialist and paying for the consultation yourself. The only wrinkle: You may have to fight to get the plan to pay your bill later and the insurer could argue that it's under no obligation to consider this second doctor's recommendation.
If the second neurosurgeon thinks you should have some different procedure, you may have to convince the health plan to pay for it. Of course, there is an underlying assumption that if the health plan paid for the second consultation, it will be willing to follow through on the results.
Another silver lining for you is the fact that having just one neurosurgeon on the approved list of doctors might be a good thing, notes Dr. Vincent Riccardi, who runs American Medical Consumers. If you have to get a second opinion, you'll probably be getting it from a doctor outside the plan, who won't have any kind of conflict of interest in providing an honest opinion. Many patients have the opposite problem they wonder whether to trust a second opinion from another doctor within the same plan.
Dr. Riccardi also offers this bit of advice: If this neurological consultation is part of an ongoing, chronic illness, there's a chance the health plan has assigned a case manager to keep track of your care and to consider the bigger picture. You could appeal to the case manager to find you another neurosurgeon.
In the long run, you might also consider changing health plans if this one severely restricts your choice of doctors. Some HMOs are a little more lenient. Better yet, to be sure you have a choice of all the specialists in the community, join a "point of service" plan, which gives you the preventive care benefits of an HMO with a wider choice of physicians. Of course, if you live in a rural area, the lists of doctors might naturally be limited. Keep handy the name of the closest teaching hospital associated with a medical school, where good specialists can often be found.