Joint replacement surgeries are very successful at relieving pain and restoring function. Your surgeon has the skills to perform your joint replacement and the therapist helps you regain motion, strength, balance, and endurance. It can be hard to tell the true cost of a joint replacement. Surgery Costs | Hip and Knee Care (aahks.org) There’s lack of clarity with the billing process. There’s also all the work provided by healthcare staff before, during, and after surgery. The cost of a joint replacement surgery can vary depending on the following:
- Location or region of the country
- Negotiated contractual agreements for implants
- Medications and services
- Type of facility performing the surgery
Your hospital bill will be sent to you after surgery. The bill will breakdown which portion is paid for by your insurance company and which portion you are responsible for. Several charges can show up on the bill including:
- Facility (hospital) fee
- Anesthesiologist fee
- Surgeon fee
- Other fees can include durable medical equipment (walker, cane, crutches); medications; and therapy
Who Pays for Your Surgery?
with your joint replacement. The amount you are responsible for depends on your insurance plan. Before surgery, it is important to make sure your surgeon and their hospital are both “in-network” with your insurance company. This will help to avoid extra costs. Insurances usually pay for the work of the surgeon and anesthesiologist along with your hospital stay. Some plans do not fully cover the required medications, laboratory tests, and/or your therapy visits after surgery. Therefore, it is a good idea to review your plan. You should be looking to see how much you will be responsible for after surgery.
Insurance companies usually cover routine follow up care for the first 90-days after surgery (also known as the “Global Period”). This care typically includes follow up appointments, most blood work, and x-rays. Yearly checkup appointments are recommended for your joint replacement. These visits with your surgeon are not covered within the Global Period. They fall under a regular doctor’s visit. They may require a co-pay, depending on your insurance plan. It is important to keep your follow up appointments immediately after surgery and for the years to come.
This is to make sure your hip or knee replacement keeps working well Follow-Up | Hip and Knee Care (aahks.org). Patients should keep in mind that your joint replacement can wear down and/or fail over time just like your car. If a problem does arise, the outcome is usually better if caught and addressed earlier rather than later. Any issues that may need further surgery are covered by most insurances.
If your insurance plan has a deductible, you must pay this amount before the insurance will cover the costs to have your joint replacement surgery. For the most part, insurance deductibles usually last an entire calendar year. This means that if you meet your deductible earlier in the year, you will not be responsible for any medical costs until the end of the year when the deductible starts over again.
Typically, the earliest you can have your second joint replacement is about 3-6 months. Because of this, some patients with two bad joints may plan to have both their joint replacements during the same year to save money. Please keep in mind that not every patient is a candidate for two joint replacements in a year. It is up to your surgeon to decide when it is safest to proceed with a second joint replacement surgery. A joint replacement surgery should not be performed because it is “cheaper” to do so.
If you are trying to have your joint replacement before the end of the year, we suggest talking with your surgeon as early as possible. It can be difficult to “squeeze” you onto the surgery schedule during the busy holiday seasons.
Authorization for Surgery
Just because you have hip or knee arthritis does not necessarily mean you need immediate surgery. Arthritis, the most common reason for a joint replacement, is a disease that gets worse with time. Conservative (non-operative) treatments including activity modification, anti-inflammatory medications, physical therapy, joint injections, weight loss, and bracing are usually prescribed to help manage your arthritis. When the arthritis pain and loss of function limits your daily activities, you and your surgeon will decide together when and if a joint replacement is right for you. Keep in mind, some insurance plans may require you to have failed certain “conservative treatments” over a certain period of time before they will approve joint replacement surgery.
A majority of insurance companies require that providers receive prior authorization for surgery, before the insurance company provides coverage and payment. This protects the patient from having any surprise charges after surgery. Your surgeon’s office or the hospital usually get this approval from the insurance company.
If you decide that you need help to cover the costs with your upcoming surgery, you may be able to buy extra insurance or make changes to your current policy. Insurances usually have an “open enrollment” period. This is when changes can be made to your current plan without penalty. You will have to check with your insurance company but usually these periods are only offered once or twice a year.
Today, over 7% of all joint replacement surgeries are done with the aid of computer/robotic technology. This number is expected to grow over the years to come. For some cases, your surgeon may ask for a special CT scan or MRI test. This helps them perform your surgery. Several insurance companies are starting to question the need for these additional tests. Research is still ongoing to see if computer/robotic assisted joint replacement leads to better outcomes compared to standard surgery. If your surgeon thinks computer assisted surgery is needed for your case and the insurance company does not cover the test, you may be left paying the bill. Right now, this is a hot topic for insurance companies. Surgeons, hospitals, and national organizations such as AAHKS are continuing to study the outcomes of joint replacement with these new technologies. Further research is needed to see if these technologies can improve long term outcomes after joint replacement. Computer Assisted Surgery | Hip and Knee Care (aahks.org)
Physical therapy is a necessary part of the recovery process after a joint replacement surgery. In the past, joint replacement patients would spend weeks at a rehabilitation facility. They were there to recover after surgery. These facilities have become very expensive for insurance companies. So, this option is usually for more complex patients. Today, if your surgeon recommends outpatient physical therapy, some insurance companies only cover a certain number of visits after surgery.
It is important to know this information before surgery. It will help your therapist design an appropriate rehabilitation program for you within the allotted number of therapy visits to maximize your recovery. Please keep in mind that your therapy visits may require a co-pay. You will want to check your insurance plan about this.
It is important to know the limits of your insurance policy. Please keep this information up to date with your surgeon’s office. If you lose your insurance and surgery is needed, hospitals may have financial counseling available. This will help cover costs or lower payments after surgery. Sometimes charity care is available also. This is for those with special circumstances. Patients are encouraged to sign up for insurance coverage through their employer because of the reduced costs. If health insurance is not offered through your employer, other options are available at www.healthcare.gov.
Remember, recovery can take up to 12 weeks after knee replacement and 8 weeks after hip replacement. If you are still working, it is important to let your employer know about your upcoming surgery. You’ll need to coordinate time off while you recover. Family and Medical Leave Act (FMLA) paperwork may be needed by your employer (https://www.dol.gov/agencies/whd/fmla).
This article has been written by Matthew Bullock, MD, in collaboration with the AAHKS Patient and Public Relations Committee and peer reviewed by the AAHKS Evidence Based Medicine Committee. Links to these pages or content used from the articles must be given proper citation to the American Association of Hip and Knee Surgeons.