I was diagnosed with glaucoma when I was 72 and prescribed a medication and told to start taking a prescription drug and follow up regularly. Less than 12 months later I went to see a different eye doctor in my city and they added on to the prescription. Medicare said that the 2nd visit 10 months later was not a second opinion and would be covered (2nd opinions are in fact covered anyway). But the added new prescription is concerning to me because it has undesirable side effects. I'd like to go to another doctor to get his opinion about taking the new prescription and probably follow his treatment course. A second opinion is covered and third opinion is only covered if the first two opinions are different. Medicare has spent hours on the phone with me telling me that to determine whether my third visit will be a third opinion they will have a non-government contractor who works for the Federal program called Medicare examine both the claim submitted by the medical practice. The contractor would consider the diagnosis code and the textual notes of the doctor. Medicare's individual independent contractor's judgement would then determine whether the first two visits were opinions or treatments and thus whether my third visit was covered as a continuation of treatment or a third opinion which may or may not be covered depending on whether visit 1 and visit 2 were differing opinions or opinions at all. If disagreed with the findings of the independent Medicare contractor who might be 19 years old and not have graduated from high school, then I could submit and appeal which would then get sent to a QIO, which is a Quality Insurance Officer (or something like that) who is another independent contractor hired by Medicare. This person could also be 18 years old and a high school dropout. Then that potentially uneducated person very likely doesn't know the mountains of Medicare law that would take a trained Medicare lawyer decades to absorb and may hardly pay attention to the dispute anyway. If you don't like the QIO's judgement you have the option of fighting the case all the way up to through the court system.
I have no desire to fight something all the way through the court system. I'd like to determine in advance whether going to see a third doctor would be covered. I think that's reasonable. Don't you? Can someone voice an opinion about whether he or she thinks seeing a third doctor would be covered, or how I could go about determining that?
Also, in this case the "insurance company" is Medicare, which is of course not a "company" at all. It is not possible to "read the policy" of Medicare. Medicare is a set of laws the meaning of which and practical application are interpreted by administrative bodies which then publish on Medicare.gov bullet point explanations with few specific rules but rather more accurate more "general guidelines" about what is and what is not covered. Sometimes the rules are somewhat specific (example: 3rd opinion for surgery or serious therapy only covered if 1st and 2nd opinion are different), but more typically they are just fairly vague guidelines like "anything is covered that is 'Medically Necessary.'"
The issue is not whether the doctors offices would accept me as a patient for my third visit. Of course they would. While that is irrelevant, what is not irrelevant is what billing code they would use to submit the charges to Medicare for reimbursement and whether the contractor who reviews the claim would accept that as reimbursable. For example, if they use the new patient code 54002 along with the patient notes that I had been previously diagnosed, then could it be another opinion? That's all up to the GED-holding 18 year independent contractor for Medicare who determines that while sitting in his underpants at home on a Wednesday at 11am while watching TV.
Regarding your one bullet point stating the Medicare-covered screening frequency for Glaucoma is 12 months: Again, that's not relevant here because I already have a diagnosis of Glaucoma. Needless to say doctors offices don't screen for Glaucoma if you've already been diagnosed for Glaucoma, so, no, I will not be getting a bill based on your assertion. I might get a bill because it's a third opinion, but not because I exceeded the screening frequency. I thought I made it pretty clear that I had already been diagnosed in my initial forum post above when I wrote in the very first, "I was diagnosed with glaucoma when I was 72..." Perhaps I should have put that in the title or otherwise made it clearer.
If anyone is willing to contribute to the substance of the question I'd be extremely appreciate of your imparting any knowledge, wisdom or experience relating to the original questions above.
•If you are at high risk for glaucoma Medicare will cover an eye exam by a state-authorized eye doctor once every 12 months. Should you be hopping more often than that, you'll be getting a bill.