How to Choose a Healthcare Specialist: Questions to Ask Before Your Visit

Step 1: know what kind of specialist you need

Specialties can overlap. Heart rhythm problems, for example, may be handled by a general cardiologist or by a cardiac electrophysiologist. Your primary care clinician is usually the best person to tell you which kind of specialist fits your situation, and many will suggest names.

Referrals and your health plan

Whether you need a referral depends on your coverage, not on the specialist:

• Original Medicare: Medicare.gov's comparison of Original Medicare and Medicare Advantage says that in most cases you do not need a referral to see a specialist.
• Medicare Advantage HMO plans: according to Medicare.gov's HMO plan page, in most cases you need a referral to see a specialist, and you generally must use doctors in the plan's network except for emergency and out-of-area urgent care. Certain services, like yearly screening mammograms, do not require a referral.
• Other plans: employer, Marketplace and Medicaid plans set their own rules. The plan's member handbook or customer service line has the answer.

Seeing an out-of-network specialist can mean paying the full cost, so check the plan's provider directory, then call the office to confirm they still take your plan.

Step 2: check the basics in public records

Specialty codes in the NPI record

Every provider's NPI record lists one or more taxonomy codes that describe the kind of care they say they give. A profile on this site shows those codes and marks the primary one. The codes are chosen by the provider, so treat them as a starting point. Our taxonomy guide explains how to read them.

State license

A clinician must hold a license in the state where you are treated. The state board is the only authority on whether that license is active and whether there are public disciplinary orders. The Federation of State Medical Boards lists every state medical board with a link to its website, and each clinician profile on this site links to the board for the practice state. See our license verification guide for details.

Board certification

Board certification is granted by a specialty board to physicians who meet that board's standards, and each board sets its own requirements. It is voluntary and it is separate from the license. Board certification is not part of NPI or Medicare records: CMS's data dictionary for the Doctors and Clinicians file says it has no board certification information, so neither the NPI Registry nor this site can confirm it. Check it directly:

• For boards that belong to the American Board of Medical Specialties, use Certification Matters.
• For osteopathic boards, the American Osteopathic Association points patients to the FSMB's DocInfo.org search to check licensure and board certification.

Education

For clinicians in the Medicare Doctors and Clinicians file, CMS publishes a medical school and graduation year. Profiles on this site show them only when Medicare lists them. A graduation year is not the same as years in practice, and the CMS data dictionary notes that the file has no residency data, so ask the office about training in your condition.

Hospitals and groups

The same CMS file names the group practice a clinician works with when their Medicare enrollment is linked to one, and profiles show these groups when they are present. Hospital privileges, the right to admit and treat patients at a particular hospital, are not in NPI data, and we do not show hospital affiliations. If it matters where a procedure would take place, ask the office which hospitals or surgery centers the specialist uses.

Step 3: understand costs before the visit

If you have Original Medicare, the most important cost question is whether the specialist accepts assignment. Medicare.gov explains on its assignment page that a provider who accepts assignment agrees to charge you only the Medicare deductible and coinsurance. A non-participating provider may accept assignment case by case, and when they do not, they can in many cases charge up to 15% above the Medicare-approved amount, called the limiting charge. Providers who opted out of Medicare are not paid by Medicare at all, except in emergencies.

The CMS Doctors and Clinicians file includes an assignment indicator, and profiles on this site show it as "Accepts Assignment" or "May Accept Assignment". Because it is a snapshot from CMS, confirm with the office before your visit. Our Medicare assignment guide explains the difference between assignment, participation and opting out.

With any coverage, it is reasonable to ask the office for an estimate of what you will owe for the first visit and for any tests they expect to order.

Step 4: prepare for the first visit

The Agency for Healthcare Research and Quality (AHRQ) publishes tips for patients on getting ready for an appointment. Among them:

• Bring all the medicines you take, including non-prescription medicines, vitamins and dietary or herbal supplements.
• Write down your questions before the visit.
• Know your current medical conditions, past surgeries and illnesses.
• Ask for written instructions or other materials about what to do next.

Questions worth asking

AHRQ's list of 10 questions you should know is a good base for a first specialist visit. It includes:

• What is the test for, and when will I get the results?
• Why do I need this treatment? Are there any alternatives?
• What are the possible complications?
• Which hospital is best for my needs?
• How many times have you done this procedure?
• Are there any side effects? Will this medicine interact with medicines that I'm already taking?

You may also want to ask practical questions: how to reach the office between visits, how long it usually takes to get a follow-up appointment, and whether follow-ups can be done by video. Our telehealth guide covers video visits.

Step 5: consider a second opinion for major decisions

For a planned surgery or another major treatment, a second opinion is a common step. Medicare.gov's page on second surgical opinions says that in some cases Part B covers a second opinion for medically necessary surgery that is not an emergency, and covers a third opinion if the first two are different. You pay your usual share of the Medicare-approved amount. Other plans have their own rules.

What public data cannot tell you

Directory data, including the data on this site, describes registrations, enrollment and Medicare billing. It does not measure:

• how well a clinician diagnoses or treats a condition;
• outcomes or complication rates for a procedure;
• whether the clinician is accepting new patients or how long the wait is;
• communication style, languages spoken or accessibility of the office.

Medicare billing volumes shown on a profile come from CMS Part B data, which by CMS's methodology covers Original Medicare claims only and leaves out services billed for 10 or fewer patients, so a low number or no data does not mean little experience. For everything on this list, the office and your own first visit are the best sources.

How to use T-MedInfo when choosing

1. Browse your city and the specialty you need, or search by name.
2. On a profile, check the specialty codes, practice address, and the state board link.
3. Read the Medicare sections, if present, for the assignment indicator and the services billed to Medicare.
4. Check board certification with the certifying board and your network status with your plan.
5. Call the office to confirm what matters to you before you book.