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Second medical opinion: What the health insurance pays

Right to a second opinion

Since those with statutory health insurance are free to choose their doctor, it is not a problem to consult another doctor for treatment. The second reviewer can settle his consulting services with the statutory health insurance. Anyone planning to obtain a second opinion should inform the attending physician about this and, for this purpose, ask for reports, laboratory values ​​and the results of X-ray examinations to be handed over. In addition, many statutory health insurance companies offer a second opinion before operations as an additional service.

Patients have the right to view the complete patient record. You can also request electronic copies of the patient record. This avoids unnecessary and health-stressing duplicate examinations and costs. Patients have the right to copies of the patient file or the available findings. The attending physician may only invoice the costs for the copies.

Regulations for certain interventions

In September 2017, the joint federal committee (G-BA) stipulated in a guideline that the new regulations for interventions in the Palatine and / or pharyngeal tonsils and Hysterectomy be valid. Arthroscopic interventions have also been part of the Shoulder joint to. In addition, those with statutory health insurance have been with planned since January 2021 Implantation of a knee endoprosthesis Entitlement to a qualified second medical opinion. This also includes the revision operation, i.e. a follow-up, replacement or corrective operation on the knee endoprosthesis, if there is a medical need. Emergency operations are exempt from the second opinion.

The planned amputation will follow shortly diabetic foot syndrome. Amputations are common in diabetic foot syndrome; alternatives include surgical cleaning of the wound, pressure relief, treatment of infections, and increased blood flow.

If an operation is pending that justifies a separate right to a second opinion according to the new legal regulation, the doctor must inform the patient at least 10 days before the planned operation that they can seek advice from specially qualified doctors on the necessity of the operation and alternative treatment options .

These second opinion doctors must be particularly qualified and independent and settle the service directly with the statutory health insurance. For a second opinion on arthroscopic shoulder operations that can be planned, for example, orthopedic surgeons and trauma surgeons as well as physicians specializing in physical and rehabilitation medicine can apply for approval.

Orthopedists, trauma surgeons and physicians specializing in physical and rehabilitation medicine can also submit an application as part of the second opinion procedure for an implantation of a knee endoprosthesis.

The Institute for Quality and Efficiency in Health Care (IQWiG) offers easily understandable information on the interventions for which a second opinion procedure is offered at www.gesundheitsinformation.de/zweitmeinung. Which doctors are allowed to give a second opinion for the respective procedure due to their special qualifications and independence can be found on the website of the medical on-call service at www.116117.de/zweitmeinung.

In addition, the patient must be informed that he can view his treatment documents and that the health insurance company will also cover the costs for the copies in these cases. In future, the doctor must also refer to lists of approved second reviewers who are sufficiently qualified to assess the interventions that have yet to be determined.

The extras of the health insurance companies

The statutory health insurance companies are also allowed to pay their insured persons for a second medical opinion on a voluntary basis for upcoming operations. It can therefore be worthwhile to ask your own health insurance company about this service.

Around half of the 62 health insurance companies in North Rhine-Westphalia, for example, offer this additional coverage. Of these 32, almost two thirds grant the additional check for operations on the spine, hips, knees or shoulder. A third of the health insurance companies with extra services in this area allow patients with a cancer diagnosis to have a further assessment by specialists.

Occasionally, the offer is also aimed at patients with an upcoming heart operation or other treatment. The second opinion procedure differs from health insurer to health insurer. Around half of the 32 NRW insurers handle it via online portals, via which documents are uploaded and advice is provided. The other half arranges an appointment with cooperating specialists.

The quality of the second opinion

In future, second opinion procedures will have to adhere to specific quality standards: both in terms of the quality of the assessment itself and the qualifications of the doctor who makes it. However, these requirements only apply to the operations mentioned above as part of the statutory second opinion procedure. In all other "normal" second opinion procedures, there are no specific guidelines.

Patients should therefore bear in mind that they may not get an independent second opinion outside of the above regulation. In hospitals, for example, economic interests also play a role. Medicine is also a business these days. The council does not always have to be unaffected by business interests.

The reverse is also true for the second opinion by the health insurance companies (see: "Extras from the health insurance companies"). There could be a risk here that the "cooperating specialists" or online portals advise against expensive interventions. Therefore, it is advisable to ask the health insurance company why the health insurance experts are particularly qualified to assess the respective treatment. It should also be clarified directly with the insurer whether costs may arise and by when the second expertise can be expected.

In addition to the health insurance companies, there are also private expert offices that specialize in second opinions. The patient has to pay for it himself.

In general, one should consider: Operations on the hips, knees or back, for example, are irreversible treatments. There are cuts in life. Life with an artificial knee is no longer the same as with a natural knee, but perhaps more painless. This decision is extremely important and needs to be thought through carefully. In order for the patient as a layperson to be able to make this decision at all, he is absolutely dependent on good advice and second advice (second opinion).