Surgical Fees and Insurance
Overview
Fees and insurance policies are the cause of a large amount of stress and confusion. Our commitment is to supply you with as much information as possible in the most open and transparent way we can. We are happy to provide estimates of out of pocket costs when you book your initial appointment so there are no surprises. Just let us know over the phone which operation you think you might need and the name of your insurance company, or whether you are self-funded.
This page is designed to explain some of the concepts involved and the likely costs which you may incur. It will cover:
- Consultation Fees
- Explanation of Surgical Fees
- Estimates
- Other Possible Costs
- No Gap and Known Gap policies
- Private Patients
- Department of Veterans Affairs
- Self-insured Patients
Initial Consultation Fee
The initial consultation will incur a fee. The Initial Consultation fee is $200 of which $84.15 can be claimed back from Medicare. This fee is payable at time of appointment and we can bill the rebated portion directly to Medicare for you.
Explanation of Our Surgical Fees
After many years of charging only either No Gap or the maximum $500 Known Gap surgical fees we are changing our fees from the 1st of July 2022.
We still participate in the available Known Gap schemes (maximum $500 out of pocket fee) for most operations including Knee Arthroscopy, ACL Reconstruction and Patella Stabilisation. Unfortunately a minority of insurance companies do not have a Known Gap scheme and for patients with these insurers the out of pocket fee will now be greater than $500 for these procedures. If you are able to advise us of the procedure you are likely to require and your insurance company when you book your initial appointment we will send you an indication of your likely surgical costs prior to your first appointment.
For Knee Replacement surgery we have now adopted the Australian Medical Association recommended surgical fee. (https://www.ama.com.au/) This will not be completely covered by the majority of insurance companies and therefore you will be liable for an out of pocket fee greater than $500. If you are able to advise us that you are likely to require a Knee Replacement when you book your initial appointment we will send you a summary of the likely surgical costs prior to your first appointment.
Estimates
We are committed to complete transparency regarding the cost involved in your surgery.
The first step in this will be providing you with a written estimate of likely surgical fees prior to confirming you initial appointment. When you book your appointment you will be asked whether you feel that you are likely to require surgery and the name of your insurance company. You will then be sent an estimate of your likely out of pocket surgical fee if that operation is required. In many cases surgery may not be required or a different operation may be recommended, however we feel that providing this information at the earliest opportunity avoids undue stress or surprise.
We also provide a formal informed financial consent to all our patients prior to surgery. This is a pre-treatment estimate of your surgical costs. This will include the total surgical fee, which you will need to pay seven days prior to the operation, and the amount which we estimate you will be able to claim back from both Medicare and your insurance company. The final amount which Medicare and your insurance company decide to reimburse may sometimes differ from our estimate.
If you require more information, please do not hesitate to call the practice during office hours.
Other Possible Costs
There may be other costs involved in your care depending on which type of treatment you require. You need to also check with your health fund to see what is covered. Potential areas of cost are:
- Hospital
- Surgical Assistants
- Implants or Prosthesis
- Anaesthetist
- Tests (Radiology, Pathology)
- Postoperative CareHealth Fund Excess
The out of pocket charges required by our anaesthetists and surgical assistants are not set by us. These often vary depending on you level of cover. We can give you an estimate of these costs prior to booking surgery. Once you are allocated to an operating list we will give you the contact details of the anaesthetist and surgical assistant should you wish to obtain the exact amount their services will incur.
Prior to surgery radiology and pathology tests may be required. These may require additional costs. Contact us and we will let you know if there are Bulk Billing options available.
Usually the hospital stay, any implants required, and the postoperative inpatient rehabilitation are all covered by your insurance.
If your private health insurance company requires the payment of an excess (often around $500) they will take this on the day of the procedure. Contact your insurer to check your policy and the excess.
Types of Private Patients
This practice caters for a range of Private patients, these include:
- Private Health Insured
- Department of Veterans Affairs (DVA)
- Self Insured (Uninsured)
Private Health Insurance
Our practice accepts all private health insurance. Our staff have a good understanding of the private health insurance and if you have any concerns or questions please contact us. We will give you all the information you need to talk to your insurance company.
Department of Veterans Affairs (DVA)
The Australian Government’s Department of Veterans’ Affairs (DVA) provides support to current and former serving members and their families through a range of benefits (including ongoing or one off payments). Our practice has a No Gap policy for DVA card holders. For further understanding on how you can apply these benefits to our service and the scope of cover please refer to: http://www.dva.gov.au/benefits-and-payments
Self Insured (Uninsured)
If you are self-funded (no private health insurance), the full hospital fee is payable on admission. Patients may be able to choose private admission even if they do not have private health insurance. Self-funded patients will be liable to pay the following:
- The gap between the Medicare benefit and any specialist’s charge
- The gap for diagnostic services (medical imaging and laboratory)
- Hospital accommodation fees (bed charge)
- Surgically implanted prostheses
Essentially this means you must meet all costs of the admission yourself except those covered by Medicare.
If you plan to self-fund we are able to give an approximate indication of the surgical fees and the total cost involved when you are booking your initial consultation. We will provide a detailed and itemised quote to you when booking surgery. This will include all specialist fees and all hospital costs. These costs are prone to change considerably between patients, particularly if the length of hospital stay changes due to complications or unforeseen circumstances. As a rough indication of the total costs (including surgical fees, anaesthetic fees, hospital costs and implants) paid by recent self-funded patients, a Knee Replacement will cost approximately $25,000, an ACL Reconstruction will cost $8000 to $11,000 (depending on meniscal repair) and a simple Knee Arthroscopy will cost $5,000 to $6000.
