Mystery Illness? 4 Ways Insurance Can Help

Incorrect diagnoses, or no diagnosis at all, often take a financial and emotional toll on patients as they struggle to navigate a complicated medical system to figure out what’s wrong with them.

If you’re having a tough time getting to the bottom of what ails you, here are 4 actions you can take – and how insurance might help cover the cost:

1. Get a second opinion. It’s always a good idea to get a second opinion, especially when there is a complex set of symptoms without a clear diagnosis. Even if you don’t gain new information, it can be helpful to have a second doctor confirm what the first has told you.

Most insurers cover the cost of a second opinion, and some may even require a second opinion before approving surgery or other medical procedures.

Patients that belong to a Health Maintenance Organization (HMO) are entitled to a second opinion, but some plans require a referral from your primary care physician if it’s to be covered. You’ll also need to see a doctor who participates with your plan in order to have the service covered.

PPO plans don’t require a doctor’s referral, but keep in mind that doctors outside your plan’s network will cost you more, and may be subject to a different deductible.

If you get conflicting opinions when seeing the second doctor, your insurer may pay for a third opinion. You’ll need to check to confirm. Medicare will pay 80% of the cost of a third opinion.

And, if you work for a large company, ask if it provides access to outside experts who will collect all of your medical records and review your case as part of your benefits package. Many do.

2. Confirm medical necessity. Insurers’ decisions about whether to pay for a medical service or procedure are based typically on whether it’s considered medically necessary.
If you must go for repeat tests and evaluations, be sure to check first with your health plan to learn what’s likely to be covered and how.

3. Work with a primary care physician. If you’re having trouble getting a firm diagnosis for a particular illness, it’s important to work with a primary care physician so that all doctor visits, tests and other treatment information are being monitored by one physician overseeing your entire case.

4. Have tests reviewed again. When we think about second opinions, we rarely consider re-evaluating the tests, such as biopsies, that are used to confirm a diagnosis. But reading test results can sometimes be more art than science, and the accuracy of the reading often depends on who’s doing it. It’s a good idea to have the tests read again. This is an especially important step to take if you’ve been diagnosed with something like cancer because those tests are often not absolutely certain. Some studies have found that the misdiagnosis rate for some cancers is as high as 44%.

As with any other type of test or procedure, diagnostic tests are subject to the rules of your insurance plan. So make sure the tests your doctor suggests are covered by your insurer and know what your costs are likely to be. It’s also a good idea to check whether the labs used to review your results are within your plan’s network.

A second reading of your tests may or may not be covered by your health plan. But if your doctor supports the medical need for the additional reading, you can appeal a denial of coverage.