[x_blockquote cite=”Noreen (Jonesboro, AR)” type=”left”]Dear Marci,

I just turned 65 and don’t feel like I know very much about what’s covered and what’s not covered under Medicare. How can my doctor help me get the services and care I’m entitled to receive, and how can I be sure her recommendations are in my best interests?

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Dear Noreen,

Your health care provider is a good source of information about Medicare and key beneficiary services. Speaking with your doctor is an opportunity for you to guarantee that you get every Medicare-covered benefit you are entitled to at the lowest cost. For example, attending your Welcome to Medicare Visit or Annual Wellness Visit and speaking with your doctor about the preventive services you could be eligible for in the coming year helps ensure that you can access free Medicare-covered screenings, counseling, and interventions as appropriate.

You have the right to seek a second opinion or the advice of a doctor other than your regular provider regarding procedures that you are not positive that you need. A second opinion is when a doctor other than your regular doctor gives his or her view about your health problem and how it should be treated. Medicare will pay for you to get a second opinion if your regular doctor recommends that you have surgery or a major diagnostic procedure. A diagnostic procedure – like a mammogram or colonoscopy – is used to help diagnose a disease or condition.

If your doctor says you need surgery to diagnose or treat a problem that isn’t an emergency, you should consider getting a second opinion. A third opinion may also be covered by Medicare if the recommendations of the first and second providers differ regarding the need for surgery. The second and third opinions will be covered even if the surgery or other procedure is not covered by Medicare. If you want a third opinion but the first and second opinions were the same, you may be able to see a third doctor for a “confirmatory consultation.” Medicare may cover the consultation if the third provider submits a claim using the right code and writes in your medical record that the services provided were reasonable and medically necessary. (Find out how to make sure your doctor provides the best possible care).

• If you are in a Medicare Advantage Plan, your plan may have different rules about second and third opinions. Call your plan to learn the rules for getting second opinions.
• Medicare does not pay for surgeries or procedures that are not medically necessary, like cosmetic surgery. (Learn more about what is not covered by Medicare.)
• Do not wait for a second opinion if you need emergency surgery. Some types of emergencies may require immediate surgery, like appendicitis, blood clots, aneurysms, or accidental injuries.

Having an open dialogue with your providers and their billing offices also creates the space for you to ask questions about services you see on your summary of medical claims. If you are unsure about a claim on your summary of health services, always take that question to your doctor for an explanation.

Noreen, here are some tips for communicating with your doctor that will be helpful as you begin your first year of Medicare coverage.

– Marci