Insurance and Joint Replacement - Your Guide to Getting Started

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.

• Medicare: www.medicare.gov/forms-help-resources/contact-medicare
• Anthem: www.anthem.com/contact-us/
• Aetna: www.aetna.com/individuals-families/contact-aetna
• Humana: www.humana.com/customer-support
• United Health One: www.uhone.com/contact-us

The costs associated with joint replacement surgery can vary widely due to many factors such as:²

• The geographical region where the surgery is performed
• The number of days in the hospital
• The type of surgery, such as total, partial, or revision
• Pre-existing conditions that require special care or monitoring
• The length of time the surgery takes
• Equipment that may be used for unexpected circumstances
• Whether or not a rehabilitation facility is necessary afterward
• Outpatient physical therapy requirements

While the prices will vary, you can expect most bills to include several primary components, including inpatient, outpatient, and other additional costs.

These costs include charges that are incurred while in the hospital and are usually the largest portion of the bill. Inpatient charges can include:

• Physician and specialist care
• Surgeons visits
• Room charges
• Equipment and prescriptions
• Anesthetic charges
• Pathology services
• Radiology
• Lab work
• Surgical assistance technology
• Physical therapy
• Administrative costs

These costs include charges that are incurred both before and after your procedure. Outpatient charges can include:²

• Pre and post-operative lab work and testing
• Follow-up visits with your surgeon
• Physical therapy once you’re home or rehabilitation/skilled nursing facility costs, depending on your hospital discharge plan

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

• Safety bars or rails
• Shower benches
• Walkers or canes
• Toilet risers
• Home care nursing visits

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

• Is the procedure covered?
• Are there any exclusions related to that surgery?
• Are both your surgeon and hospital considered in the insurance network?
• Is there coverage for services after the procedure such as physical therapy, at home health, or inpatient rehabilitation? If so, how much time and how many sessions are covered?
• Is pre-approval required for the procedure? (Some insurance companies will not pay unless the procedure was approved beforehand)

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.