Patients undergoing knee replacement, or considering it, generally have a long list of questions and considerations that need attention during the planning phase. One of the most significant concerns during this time is knee replacement cost. Learning as much as possible about the facts around this topic can help patients make an informed decision to achieve a good outcome.
That’s why we’ve created the following guide with practical information patients should know about knee replacement costs. To learn more about knee replacement surgery our experienced team provides at Outpatient Joint Replacement Center of America (OJRCA), please get in touch with us today. We’re committed to exceptional care and we understand the important role that cost and insurance coverage plays in your decision-making.
Some Basic Facts on Knee Replacement Cost
It’s critical to understand that knee replacement cost depends on a wide range of factors that vary on a case-by-case basis. Major factors include the surgeon, the surgery center and its location, any tests that are needed, the cost of surgical hardware, and the extent and scope of the knee replacement procedure. One large Tampa hospital facility has negotiated prices well over 100,000 dollars for a knee or hip replacement. According to one surgical cost estimator, the average cost for an uninsured patient receiving a total knee replacement is about $35,000. Often, patients who are paying out-of-pocket can negotiate a self-pay discount with the surgeon and surgery center.
It should be noted that the knee replacement cost figure above is an estimate for an uninsured patient. If you have a private health plan or are covered by an employer, the amount that your insurance will cover and the negotiated rate generally results in lower out-of-pocket amount. However, as most of us who have encountered coverage under health insurance or Medicare know, there are a significant number of factors that go into this determination.
What Does Insurance Cover?
The health insurance system is intended to lower costs for both patients and the larger health care system. This is accomplished by paying into a single entity that can negotiate costs with providers. A significant portion of patients have the option to receive medical insurance coverage by their employer. Uninsured patients can purchase an individual plan and can now shop for them on the health care exchanges supported by the Affordable Care Act, or ACA. Patients who have reached retirement age are supported under the state-sponsored Medicare system and often supplement this coverage with a private insurance plan.
Privately-insured people pay a monthly premium that covers them under the specifics of the plan. A very important concept to understand is the insurance deductible, which is the dollar amount that an insured patient must pay out-of-pocket before the insurance provider will start to cover expenses. After that, patients will still typically pay co-insurance, or a portion of expenses until an out-of-pocket maximum is reached. A common coinsurance split is for the insurance payer to cover 80% and the patient the remaining 20%.
In addition, health insurance plans and Medicare will generally build a network of medical providers such as surgeons and surgery centers. Providers who are in this network will have a special negotiated rate that they charge the payer. This is one significant reason why treatment costs, including knee replacement costs, can vary so much on a case-by-case basis.
This variation only grows when considering different plans and state regulations. Some health insurance coverage offers a lower premium that comes with a higher deductible.In contrast, there are some employee-sponsored health insurance packages that result in significantly reduced costs for the patient. Some employee plans may have a more selective network, which limits the choice of covered providers.
When deciding if it is time to have a knee replacement procedure, it is highly beneficial to gather any needed information on your individual coverage and if a given surgeon and surgery center is in your provider network. Getting these basics lined up on your end can help make the preparations go more smoothly as you make this critical health care decision.
Knee Replacement Costs — Other Deciding Factors
Monetary cost of a knee replacement is typically a major part of the decision, but patients should also look at it in the broader context and balance it against non-monetary consideration. First and foremost, finding a qualified surgeon and state-of-the-art surgery center can have a major impact on the outcome and should be thought of independently of the cost of the procedure.
Look for an orthopedic surgeon who has extensive experience treating your specific knee injury or condition. Increased specialization often means a surgeon who has dealt with cases that are like yours. Performing research into a surgeon’s credentials, including his or her medical school, residency, surgical fellowship and board certification can also be key indicators of their training and skill level.
Another consideration is if there are hospital-associated costs for an inpatient procedure. Patients should ask about the potential to undergo surgery on an outpatient basis at a surgery center. An outpatient knee replacement offers patients the possibility of a streamlined patient experience and the ability to be up-and-walking to begin the recovery process.
Also of importance is the possible costs of delaying or avoiding surgery when it is being recommended as the best course of treatment. These costs can be both monetary and non-monetary. Nonsurgical therapy can deliver genuine improvement and is usually seen as the initial treatment for many types of knee injury and joint pain. Patients should seriously consider surgery though if conservative treatment has been fully explored and there is still pain and limited mobility. For example, if steroid injections and physical therapy and rehabilitation are showing diminished returns, patients can end up paying a significant amount over the ensuing months and years.
Delaying knee replacement surgery may also negatively impact your relationships with friends and family, your job and your hobbies. These major quality of life concerns should be considered very closely and carefully when factoring knee replacement cost.
All of these questions and factors require working closely with your family, your treatment team and your prospective surgeon and surgery center to make a well-informed decision. Try to find surgical providers who value transparency in these concerns. Patient education and advocacy should include everything from helping you understand your diagnosis and recommended treatment plan to financing and insurance coverage questions.
Total and Partial Knee Replacement at OJRCA
OJRCA and board-certified surgeon and medical director Dr. Philip Clifford take advantage of advanced techniques to perform partial and total knee replacement surgery at our ambulatory surgery center. Even patients requiring a hospital-based procedure due to the presence of certain medical conditions can still benefit from our advanced minimally invasive procedures and unique anesthesia and multimodal pain management protocols.
We believe in exceptional whole-person care. This includes helping patients build the most cost-effective care plan possible for their needs. OJRCA works with a full spectrum of payment types and insurance carriers. A dedicated representative can help you better understand the important considerations surrounding knee replacement cost.
Reach out to us online or call 813-492-4662.