Click the headings below to learn more about insurance coverage.
Contracted Insurance Plans
If I have a contract to provide my services to an insurance company at a discount, I am “in (their) network”; if I do not, I am “out of (their) network”. Currently I am "in network" with all Blue Cross Blue Shield Insurance 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.
The hospital is financially independent from my orthopedic practice; even if I am “out of network”, the hospital may still be “in network” for your insurance plan. If I am in network for your plan, we will request that you pay in advance the amount that we estimate that your insurance contract requires. We have a financial counselor who can assist you with any questions.
We can put you in contact with the financial counselor of the hospital, who can give you approximate charges and answer any questions about insurance coverage of the hospital bill. The hospital charges will amount to the largest portion of your final bill, by far.
There will also be much smaller bills from three other professionals involved in your case: a radiologist, a pathologist and an anesthesiologist. These charges will all be significantly less than my fee.
When estimating the likely final cost of the procedure, you must also consider the conditions of your contract with your insurance company.
- What is your copay, your percentage responsibility and your out-of-pocket maximum for the year?
- How do all of these fees apply to the yearly out-of-pocket maximum?
- When does the “year” begin and end according to your plan?
Insurance companies have made this process extremely complex.
My fees are fully explained in Section IV; however, if I am “in network” for your plan, as described above, a discounted rate will be applicable to you. We can only tell you what this rate is after we see your insurance card.
Non-contracted Insurance Plans
If I do not have a contract with your insurance plan, I am considered “out-of-network”. If your insurance company does not appear on the following list, I am NOT in your network and this section applies to you.
“In Network” Plans
- Blue Choice
- Blue Cross Blue Shield Federal Employee Plan
- Blue Cross Blue Shield SC*
- Blue Cross Blue Shield State Health Plan (SC)
- United Healthcare
*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.
If your insurance plan does not appear in the above list, I am “out-of-network” with your insurance company, and the following information does apply to you.
I will bill your insurance company directly after services are provided.
Payment for Surgical Services
- I will request that you pay $4000 in advance (for primary hip or knee surgery)
- I will bill your insurance company $5000.
- Any amount the insurance carrier pays me up to $4000 will be refunded to you.
- Your maximum payment to me will be $4000.
Payment for Office Services
- I will ask you to pay 50% at the time of service.
- I will bill your insurance the full amount.
- We will reconcile the bill 3 months after services are provided.
- Any amount not paid by insurance within 3 months of the service will be your responsibility to pay.
I no longer participate with Medicare, Medicaid, Tricare, or workers compensation government plans.
If you are insured by these plans and you wish to purchase my services, we must enter into a private contract. The discounted fee schedule (see Section IV) applies. All fees for surgical services must be paid in advance. Office-based services can be paid at the time of service. Most supplemental Medicare or Medicare replacement policies won’t pay anything to a provider who is opted out of Medicare. Hospital payments and other services that are not provided directly by my office will still be handled in the usual fashion by these government plans. These costs are typically the largest portion of any surgical procedure.
- My fee for primary hip or knee replacement including the assistant fee: $5000
- Hospital fees (approximately 20% $9000): $1800*
- Anesthesiologist, radiologist and pathologist fees: $1250*
- Supplemental Medicare policy covers some percentage of the $3050 (depends on your policy): $ ?
*These amounts are presented solely as estimates for illustration purposes. I have no control over the actual cost of these services.
Global Prepayment Option (Cash Paying Patients)
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 steeply discounted rate 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.
- Providence NE Hospital $21,000 (includes implant)
- Surgeon $4,000
- Surgeon’s assistant $1,000
- Anesthesiologist $1,000
- Pathologist $110
- Radiologist $24
- Total $25,035
For your convenience, separate checks to each provider can be given to my office and we will be happy to distribute them to the various providers. The checks should be addressed to:
- Providence Hospital
- Midlands Orthopaedics
- Midlands Orthopaedics
- Critical Health Systems
- Providence Pathology Associates PA
- Pitts Radiological Associates