If your doctor has recommended joint replacement surgery, chances are you’ve already started worrying about what your out-of-pocket expenses will be and whether or not that price is worth the risks. Having an understanding of what costs you may be responsible for upfront may help calm some of the financial apprehensions you have about moving forward.
A good place to start is simply by having a conversation with your doctor and his billing staff. They can provide your first line of answers as you begin investigating your costs and coverage. Your doctor’s office should be able to provide you a list of procedural codes they will submit to your insurance provider for billing. These codes can help facilitate a specific discussion with your insurance provider. Your doctor’s office should also be able to provide you with a cost estimate for the procedure.
After talking with your doctor, call your insurance provider. Most insurance cards have a 1-800 number you can call listed on the back of the card. If you can’t find it, the following links may help you.
The costs associated with joint replacement surgery can vary widely due to many factors such as:2
While the prices will vary, you can expect most bills to include
several primary components, including inpatient, outpatient, and other
These costs include charges that are incurred while in the hospital
and are usually the largest portion of the bill. Inpatient charges can
These costs include charges that are incurred both before and after
your procedure. Outpatient charges can include:2
There could be additional charges for your joint replacement
depending on your overall health at the time of surgery. Many
additional charges include at-home care or special equipment you may
need until fully recovered, such as:2
Questions around joint replacement and Medicare or insurance coverage are common. Calling your Medicare or insurance representative is the safest way to know what coverage you have. But, in general, Medicare typically covers a portion of knee or hip replacement surgery if your doctor has deemed it medically necessary, and alternative treatments have failed to provide relief.1
If you have the basic coverage with Medicare Part A, you can expect to have 100% coverage for your inpatient charges, after the deductible, as long as you are under the maximum cost for the procedure.2
If you have Medicare Part A and B, you can expect 100% coverage of inpatient costs and around 80% of outpatient costs once both deductibles have been satisfied.2
The prescriptions you receive once you have left the hospital may be partially covered by your Medicare Part B. If you have Medicare Part D coverage, your prescriptions should be covered based on the types of prescriptions covered on your specific plan. If your doctor prescribes a drug that is not covered, consider asking them for a substitute that your insurance will cover.
Talking to your Medicare representative is the safest way to know what will be covered for your specific procedure.
If your doctor has suggested that you have joint replacement surgery, contact your insurance provider. You will want to ask them:3
Once you have the information from your insurance company, you can
ask the doctor or hospital for an estimated list of charges. Then you
will be able to take into account your deductible, co-pay, and the
percentage that your insurance does not cover based on the estimate.
This will give you a good idea of what you may need to end up paying
after the procedure.
Even if this amount is high, do not be discouraged. Many hospitals and medical centers will allow you to set up no-interest payment plans that allow you to pay a small portion of your bill monthly until it is paid in full.2
Don't let your fear of paying for surgery prevent you from experiencing the benefits. Talk to your doctor and insurance company about your options.