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How
to get a Second Opinion Outside your HMO
To get Kaiser to pay for an outside second or third opinion it can be a long drawn out process. IN WRITING to member services request a second opinion from Kaiser. If not satisfied, request another. You have the right to three opinions before Kaiser will pay you to have an outside of Kaiser opinion. Sometimes they will allow it after two internal second opinions. Kaiser will then be obligated to honor, and pay for your request to have a consult with any outside physician of YOUR choice. ALWAYS submit these requests in WRITING and hand deliver them to Member Services. Request a stamped date be placed on it and get a copy of your complaint with the stamped date on it.
You may have to pay a co-pay for the outside of Kaiser second opinion. This information is as per California Health and Safety Law HSC 1383.15
Please read the following link first as your second opinion physician may also not place your best interests first. In fact they may be under contract to agree with the Kaiser physician that you are questioning or wish confirmation of diagnosis and treatment of: https://kaiserpapers.com/selfincrimination/pooldoc.html
The following should be an fairly simple process, at least according to California state law HSC 1383.15 which is included below in this document. Unfortunately for everyone that is not the case and in fact this process can become a nightmare, delaying proper medical treatment and creating confusion for those seeking help.
As a citizen of this country you cannot be harmed, intimidated, threatened, humiliated, etc., if you attempt to get a second medical opinion. As a patient of Kaiser you will find in many cases that they will attempt to do all of the above to you in my opinion. Don't let anything they tell you affect your decision to obtain a second or third medical opinion outside of Kaiser Permanente.
It is every person's responsibility to themselves and their loved ones to oversee all aspects of each others medical care. It is your responsibility and your right to know what is being done and what else can be done. If Kaiser or any other HMO or even any physician says nothing can be done, or that a certain operation or procedure needs to be done you have the right to question this information. In fact a prudent person would have it verified from an outside source that has no affiliation with the first source. No affiliation with the first source related to the document at: https://kaiserpapers.com/selfincrimination/pooldoc.html which indicates that unknown to you the second opinion physician may be contracturally obligated to provide to you a diagnosis exactly as Kaiser's attorney's tell them to.
If you receive a contradictory diagnosis then a prudent person would also take the extra step, to insure they were doing the right thing by seeking yet another opinion. In doing so you should end up with a 2 to 1 ratio which seems to me to be the logical thing to do.
Don't be intimidated by this process and you will be successful. If you have to go to a Urgent Care Center or a Free Clinic to get help then do it. If you insist on keeping Kaiser for your insurance then don't waste valuable time arguing with Kaiser staff that probably won't be of any help to you anyway. Empower yourself as a citizen and use the law to your advantage to get a non biased second opinion outside of Kaiser Permanente. This will save you furture grief, possible regret that you did not act prudently at the time and will give you the confidence that you need at this time of medical need to make the right decision for your or your loved one.
Don't count on Kaiser Permanente offering to pay for a second or third medical opinion outside of their system either. It could happen but don't count on it. If they had wanted to spend the money to make sure that they were correct they would have already offered it.
The HMO does not have to pay for a second opinion outside its own network. If it refuses to follow the outside advice, the patient has to go for IMR - Independent Medical Review. If IMR agrees with the outside doctor, the patient can sue for reimbursement for what the outside second opinion cost. It is unlikely that DMHC would tell the HMO to pay it. The above link with information on Independent Medical Review information often uses Kaiser physicians. See: https://kaiserpapers.com/selfincrimination/retiredoc.html and then because DMHC states that the employed physicians are not currently part of the health plan in question read: https://kaiserpapers.com/selfincrimination/pooldoc.html because they may be under contract with Kaiser and DMHC does not know about it.
The following is what the State of California says about your right to a second opinion outside of Kaiser Permanente. The following is from the Health and Safety Code within the State of California. HSC 1383.15.
(a) When requested by an enrollee or participating health professional who is treating an enrollee, a health care service plan shall provide or authorize a second opinion by an appropriately qualified health care professional. Reasons for a second opinion to be provided or authorized shall include, but are not limited to, the following:(1) If the enrollee questions the reasonableness or necessity of recommended surgical procedures.
(2) If the enrollee questions a diagnosis or plan of care for a condition that threatens loss of life, loss of limb, loss of bodily function, or substantial impairment, including, but not limited to, a serious chronic condition.
(3) If the clinical indications are not clear or are complex and confusing, a diagnosis is in doubt due to conflicting test results, or the treating health professional is unable to diagnose the condition, and the enrollee requests an additional diagnosis.
(4) If the treatment plan in progress is not improving the medical condition of the enrollee within an appropriate period of time given the diagnosis and plan of care, and the enrollee requests a second opinion regarding the diagnosis or continuance of the treatment.
(5) If the enrollee has attempted to follow the plan of care or consulted with the initial provider concerning serious concerns about the diagnosis or plan of care.(b) For purposes of this section, an appropriately qualified health care professional is a primary care physician or specialist who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to the particular illness, disease, condition or conditions associated with the request for a second opinion. For purposes of a specialized health care service plan, an appropriately qualified health care professional is a licensed health care provider who is acting within his or her scope of practice and who possesses a clinical background, including training and expertise, related to the particular illness, disease, condition or conditions associated with the request for a second opinion.
(c) If an enrollee or participating health professional who is treating an enrollee requests a second opinion pursuant to this section, an authorization or denial shall be provided in an expeditious manner. When the enrollee's condition is such that the enrollee faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or lack of timeliness that would be detrimental to the enrollee's ability to regain maximum function, the second opinion shall be authorized or denied in a timely fashion appropriate for the nature of the enrollee's condition, not to exceed 72 hours after the plan's receipt of the request, whenever possible.
Each plan shall file with the Department of Managed Health Care timelines for responding to requests for second opinions for cases involving emergency needs, urgent care, and other requests by July 1, 2000, and within 30 days of any amendment to the timelines. The time lines shall be made available to the public upon request.
(d) If a health care service plan approves a request by an enrollee for a second opinion, the enrollee shall be responsible only for the costs of applicable copayments that the plan requires for similar referrals.
(e) If the enrollee is requesting a second opinion about care from his or her primary care physician, the second opinion shall be provided by an appropriately qualified health care professional of the enrollee's choice within the same physician organization.
(f) If the enrollee is requesting a second opinion about care from a specialist, the second opinion shall be provided by any provider of the enrollee's choice from any independent practice association or medical group within the network of the same or equivalent specialty. If the specialist is not within the same physician organization, the plan shall incur the cost or negotiate the fee arrangements of that second opinion, beyond the applicable copayments which shall be paid by the enrollee.
If not authorized by the plan, additional medical opinions not within the original physician organization shall be the responsibility of the enrollee.
(g) If there is no participating plan provider within the network who meets the standard specified in subdivision (b), then the plan shall authorize a second opinion by an appropriately qualified health professional outside of the plan's provider network. In approving a second opinion either inside or outside of the plan's provider network, the plan shall take into account the ability of the enrollee to travel to the provider.(h) The health care service plan shall require the second opinion health professional to provide the enrollee and the initial health professional with a consultation report, including any recommended procedures or tests that the second opinion health professional believes appropriate. Nothing in this section shall be construed to prevent the plan from authorizing, based on its independent determination, additional medical opinions concerning the medical condition of an enrollee.
(i) If the health care service plan denies a request by an enrollee for a second opinion, it shall notify the enrollee in writing of the reasons for the denial and shall inform the enrollee of the right to file a grievance with the plan. The notice shall comply with subdivision (b) of Section 1368.02.
(j) Unless authorized by the plan, in order for services to be covered the enrollee shall obtain services only from a provider who is participating in, or under contract with, the plan pursuant to the specific contract under which the enrollee is entitled to health care services. The plan may limit referrals to its network of providers if there is a participating plan provider who meets the standard specified in subdivision (b).
(k) This section shall not apply to health care service plan contracts that provide benefits to enrollees through preferred provider contracting arrangements if, subject to all other terms and conditions of the contract that apply generally to all other benefits, access to and coverage for second opinions are not limited.