II. Quick Reference for Insurance Coverage

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.

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”.

Current “In-Network” Plans

  • Blue Cross Blue Shield of SC PPO*
  • Blue Cross Blue Shield State Health Plan (SC)
  • Blue Choice
  • Blue Cross Blue Shield Federal Employee Plan
  • Blue Cross of SC EPO
  • United Healthcare

*Most standard Blue Cross/Blue Shield PPO plans from other states have a reciprocal agreement with Blue Cross of SC, and are therefore, also “in-network”. They typically display a suitcase on their card. HMO plans typically are not part of this network. We can tell you if this applies to your Blues plan.

The Midlands Orthopaedics Surgery Center (MOSC) is where I perform most of my operations in an outpatient format. The surgery center has contracts with all insurance companies that I am contracted with above. In addition, they have contracts with Aetna and Cigna and several others. Because I treat patients from all over the country, we come across many different health plans.

Our MOSC will work with insurance carriers that don’t have contracts with MOSC. Our outpatient facility fees are likely much lower than what they are accustomed to paying at most hospital across the country. Here in Columbia, we charge about 20% of what our three major hospital systems do. If they are smart, most insurers would gladly pay our fee even if they don’t have a preexisting contract. Unfortunately, many insurance companies are fairly bureaucratic and inflexible.

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.

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.

Current “In-Network” Plans

  • Blue Cross Blue Shield of SC PPO*
  • Blue Cross Blue Shield State Health Plan (SC)
  • Blue Choice
  • Blue Cross Blue Shield Federal Employee Plan
  • Blue Cross of SC EPO
  • 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 $5000 in advance (for primary hip or knee surgery)
  • I will bill your insurance company $6000.
  • Any amount the insurance carrier pays me, less than $1000 will be refunded to you.
  • Your maximum payment to me will be $6000.

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.

Government Plans

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 simplified 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 $6000
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 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.

Fee Type


1. Midlands Orthopaedics Surgery Center (facility) $18,000 (includes implant)
2. Surgeon $4,800
3. Surgeon’s assistant $1,200
4. Anesthesiologist $1,000
Total $25,000

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.

Phone Consultation

If you are interested in determining if you are a candidate for surgery, please mail your completed new patient forms to the office and include a digital x-ray.

Dr. Gross will call you back to discuss your options.

Download New Patient Forms

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Irmo, SC 29063

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