South Carolina Hip Preservation Center

The American Medical Association publishes a set of codes that surgeons are required to use when billing for procedures called “current procedural terminology”. These codes gradually change to reflect changes and advances in surgical techniques. The system often does not provide a code for the latest procedures. When we bill an insurance carrier, they use these codes together with my fee to determine what they will pay on your behalf. The codes I bill most frequently appear below.

(Updated 3/2023)

I have contracted with the following carriers for reduced fee schedules as of 1/1/2023; therefore, I am considered an “in-network” provider with these plans:

*Most standard Blue Cross/ Blue Shield plans from other states have a reciprocal agreement with Blue Cross of SC, and are therefore also “in network”. We can tell you if this applies to your Blues plan. 

In this country the medical payment system is hopelessly complicated.  No one fully understands it.  We spend incredible amounts of money trying to run and control it.  If you were to enter a hospital and pay for a hip replacement privately, it would cost you over $100,000. The government (Medicare and Medicaid) pays hospitals about $23,000 (facility fee), and surgeons $1000 (professional fee) for this operation. 

I have determined that hospitals (using the best joint implants that cost $6000 each) can probably provide the service at a cost of $15,000. With a government payment of $23,000 they make a healthy profit of $8000 (35% profit margin). On the other hand, the government proposes to pay MOSC a $8000 facility fee for the same procedure… clearly a money losing proposition for us. This is why I cannot offer my procedure to government insured patients at the MOSC, I must take these patients to the hospital instead, where the government pays a generous fee. Patients not covered by government plans are routinely billed over $100,000 for joint replacement facility fees at hospitals. Most insurance contracts provide for some discounts, but the costs are still exorbitant.

I estimate my office overhead cost for providing the professional services for a joint replacement is approximately $2000.00, which means I would actually lose $1000 on each government insured patient on whom I performed surgery. If I were to become a hospital employed surgeon, the calculus would change. The government would pay the hospital higher fees for the same services (They would add facility fees on top of professional fees for office-based work). Also, the hospital would subsidize my Medicare professional fee from some of their facility fees collected on my patients. Therefore, hospital employed surgeons get paid reasonable fees on Medicare patient services. I am unwilling to give up my autonomy in private practice, therefore I am unable to accept the deal offered by the government and I must make a private contract with you if you are covered by a government plan.

This calculation illustrates the tremendous damage the government does as it distorts the payment system. It forces doctors to become hospital employees. We lose control of many aspects of patient care to professional hospital managers.

My global prepayment contract was developed to offer joint replacement to anyone who does not have insurance coverage at a reasonable cost.  We can offer these rates because we know we will receive the full payment, and we will not have to devote office resources to seek late payments from insurers.  If your insurance company does not have a contract with our Surgery Center or Midlands Orthopaedics, they certainly can choose this option as well; however, they must prepay the entire amount.  This offer is not valid after services have been rendered. 

The global prepayment option has been created to allow patients who do not have insurance, or whose insurance does not cover hip resurfacing, to purchase this service at a reasonable rate. It is a discounted rate (compared to what this would cost you at a hospital) that does require payment in full of all charges prior to surgery.

Additional charges will only apply if there are unusual problems or complications requiring a significant increase in the standard care. Circumstances requiring additional charges occur in less than 1% of cases.

If you are medically not a candidate for outpatient services, I will charge you for surgeon and assistant fees. We will refer you to the hospital to arrange for facility and anesthesia fees. Prepare for a bill in excess of $100,000 from them.

A. "In-network" vs."Out-of-network"

I do accept payments on your behalf from any private insurance company. For all procedures we contact your insurance company and pre-certify the surgery and bill your insurance company. If I have a contract to provide my services to an insurance company at a discount, I am “in-network”; if I do not, I am “out of (their) network”. If I am considered “in-network” for your health insurance company, please see Section B - Standard fee schedule. If I am “out-of-network" for your health insurance plan, please see Section C - Simplified fee schedule.

B. Standard fee schedule

Insurance discounts may be applicable. This option applies to patients who are covered by most Blue Cross Plans including out of state plans. I am “in-network” for these plans. You pay only what is required by your plan. I receive the portion of the rest of my standard fee schedule from your insurance plan. I have agreed to provide my services to them at a discount. Our office will let you know what your responsibility is according to your insurance contract. If I do not have a contract with your insurance company, I am “out-of-network” with your plan.

C. Simplified fee schedule

This schedule applies to Medicare, Medicaid, Tricare and Workers' Comp. With these insurers, you are responsible for my bill and cannot submit it to your government insurance plan or to most Medicare supplemental policies. This schedule also applies to any patient who has a private non-government insurance company for which I am “out-of-network”.

X-rays

Depending on the nature of the evaluation and whether right and/or left sides are included, 3-13 images may be required. The total charge equals the number of images x $50. Typical examples are included below.

Surgical Fees

These fees will be quoted to you in advance of surgery and are firm quotes. If the operation becomes more complicated than I anticipated, no extra charges will apply. The operation types are grouped in only a few categories to keep it simple.

Complications may require repeat surgery, which will be billed separately. Revision surgery is more prone to complication. Treatment for an infection will often require two or more difficult and/or complex procedures. Some portion of surgical fees must be paid in advance. The amount depends on your insurance type.

Office visits, injections and x-rays are payable at the time of service. Credit card or Capital One financing is accepted. Late payment will result in a 20% surcharge.

Many types of insurance plans exist. I will outline some of the more common ones in very general terms.

Click on the headings to learn more about each insurance plan.

There are typically three components to payment for any surgical procedure. By far, the largest charge is the facility fee.

1. Surgeon/Assistant Professional Fee

These will be discussed in detail in this section.

2. Facility Fee (Surgery Center or Hospital)

Most of my procedures can be done as outpatient procedures at our Surgery Center (Midlands Orthopaedics Surgery Center MOSC). The quality of care and the overall experience are better than at a hospital. The cost is less than 20% of what most hospitals charge. However, usually most of the excess cost of hospitals is borne by the insurance company.

Government plans reimburse us so much lower than they do hospitals that I must perform these operations at the hospital. Some insurance companies also do not wish to contract with us and instead prefer to pay a much higher fee at the hospital, therefore these cases must also be scheduled at the hospital. Finally, a minority of patients have serious enough comorbidities, that they require longer monitoring overnight at the hospital and cannot be done at MOSC. At this point, I perform over 90% of my cases at the MOSC.

The partners at Midlands Orthopaedics and Neurosurgery own the majority of the MOSC. Therefore, our business office will advise you if and how your operation will be covered by your insurance plan if the operation is done at MOSC. If the operation is done at the hospital (where we have no control), we will refer you to their business office to provide cost estimates.

3. Anesthesia Professional Fee

If the procedure is done at MOSC, we will provide financial details. If it is done at the hospital, then they will advise you.

Click the headings below to learn more about insurance coverage.

updated 10/8/2023 tpg

• I accept payment from any insurance company (except Medicare, Tricare, Workers Compensation, and Medicaid) even if I am not in their network.
• I will bill your insurance company (except Medicare, Tricare, Workers Compensation, and Medicaid) for my services, even if I am not in their network.
• I am only contracted with Blue Cross and accept their contractual rates.
• Out-of-state Blue Cross also is handled under contracted rates.
• You are responsible for the amount insurance doesn’t pay.
• For surgical services, advance payment is required.
• For office services, payment is requested at the time of service.
• My simplified fee schedule is published later in this article.
• I only have discounted contracts with a few insurance companies because most demand discounts that are too steep.

The medical payment system is unnecessarily complex and bewildering. I believe that one of the primary problems with healthcare in America is a lack of transparency in the system that pays for care. I have prepared this document in an effort to shed some light on this system. The typical sources for healthcare bills are medical professionals, hospitals, pharmacies, and home health agencies.

Professional fees include charges for office visits, x-rays in the office, and surgical fees. These fees include your medical doctor, surgeon, anesthesiologist, radiologist, pathologist, and possibly an in-hospital internal medicine consultant. Additionally, a separate facility fee (hospital or surgery center) bill will include numerous items such as room fees, orthopaedic implants, medicines, physical therapy fees, and supplies. 


Many insurance companies have contractual discounts with professionals and facilities (hospitals and surgery centers). Also, these same insurance companies have complex contractual agreements with patients (co-pay, deductible, in-network and out-of-network rules, out-of-pocket maximum). Neither patients nor physicians have much control over these contracts; insurance companies are in the position to pressure us into accepting these arrangements. Therefore, determining your final cost in advance is extremely complicated.

An insurance counselor in my office can assist you in estimating the likely cost for my orthopaedic professional services as well as facility fees at Midlands Orthopaedics Surgery Center (MOSC). If you are having surgery at the hospital instead, we can also connect you with an advisor at the hospital to help you estimate the hospital expense, which is the most costly component.

The services I offer as an orthopaedic surgeon and joint replacement specialist are billed in the following categories:

• Office visits
• X-rays in office
• Injections in the office
• Surgical fees
• Braces and Equipment
• MRI

I am currently only contracted with Blue Cross to treat patients covered by their various plans for a discounted fee.  I bill the insurance company my normal fee; they then disallow a certain percentage as the contractual discount which I am obligated to write off. You pay your copays and deductibles as required by your insurance contract. Most out of state Blue Cross plans have reciprocal arrangements with SC Blue Cross and I am therefore also "in network" for most OOS Blue Cross. As demands for my services increase, I may also end my contract with Blue Cross.  Generally, specialists with the least demand for their services feel compelled to sign contracts with more insurers at higher discounts.

I will provide detailed figures so you will be well-informed about costs before you choose me as a consultant and surgeon.  First, I will provide a quick reference section to allow you to quickly estimate what your likely costs will be, depending on your insurance type. If you want to learn more about the whole system and how you fit into it, please read the remaining sections for Fees and Insurance.