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Paying for knee replacement surgery

Description

Knee replacement and all of the care you will need before and after surgery is costly. Most insurance plans cover many of these costs. However, finding out the total cost weeks before your surgery can save you trouble and money afterward.

What will knee-replacement surgery cost?

The cost of knee replacement may vary in different parts of the United States and between different hospitals and surgeons. It can cost anywhere between $16,000 and $70,000 without any insurance in the United States. But it may cost more or less in your area.

This amount includes the cost of:

  • Visits with your orthopedic surgeon before surgery, including your physical exam and medical history
  • Surgeon fees for the surgery itself
  • Cost of care while you are in the hospital after surgery

Serious complications during or after surgery may add extra costs -- up to $20,000 or more.

Get information from your insurance company

Most health insurance plans and Medicare pay for most of the costs of knee-replacement surgery. Your surgeon's office and your hospital may call your insurance company directly to discuss your coverage for knee replacement.

Even if your insurance covers your knee-replacement surgery, you may still need to pay part of your bill. Most insurance plans have copays, coinsurance, deductibles, or out-of-pocket expenses. These are the costs that you pay.

Often, your surgeon and the hospital can tell you what part of the costs are covered and what you will need to pay yourself.

Check to see whether your insurance will also cover:

  • Changes that you make to your home to prepare for your recovery. For example, you might add handrails, buy special pillows or pads, or special equipment to help you reach or pick up items in the home.
  • Special canes, braces, crutches, or walkers.
  • Special cooling sleeves for your knee during recovery.

How to find out what your insurance or Medicare will pay for

Sometimes, your insurance will not pay for care unless they approve it before the care occurs. This is called "preauthorization." Find out exactly what your insurance company will cover before you have surgery. Be sure to ask:

  • Is the type of surgery you are having covered?
  • Are there any exclusions to knee-replacement surgery in your plan? In other words, are there any knee-replacement surgeries your insurance does NOT cover?
  • Does your surgeon and hospital have a contract with your health insurance plan? If they do not, this means your insurance may not pay for you to use this surgeon and have your surgery at this hospital. Or they may not pay for as much of the bill.
  • Are home physical therapy, home-health nurses or aides, or other services after you go home covered? You may need these after you go home.
  • Is outpatient physical therapy covered and where? You may also want to know how many sessions your insurance will cover so you can plan your recovery with your physical therapist.
  • Is a stay in a skilled nursing facility or rehabilitation unit covered? You may need to go to such a facility to recover further after you leave the hospital and before you go home. Ask whether your insurance covers the stay and the facility you have chosen to go to.

If your insurance company denies or refuses to cover your surgery, you can appeal this decision. Find out why your coverage was denied and submit an appeal. Do all of this long before you go to the hospital for your surgery.

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Review Date: 8/9/2018

Reviewed By: C. Benjamin Ma, MD, Professor, Chief, Sports Medicine and Shoulder Service, UCSF Department of Orthopaedic Surgery, San Francisco, CA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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