There must be an easier way to find out the cost of having my hip replaced (out of pocket expenses)?
I’m with BUPA and they only give a list of Dr’s who may or may not participate in their no gap scheme on a case by case basis. I’ve been to two specialists now and each time have to pay an initial consultation fee between $250-300. Only then will they give me a quote with all the out of pocket expenses of between $4000-$5000. I tried emailing and calling others with the same response. I called BUPA and they said the same, it’s case by case and will need a consultation. This is impractical and the cost would add up quickly and they always need more x-rays even it I had one a month ago.
I’ve put this off for many years due to my younger age at 47 and now at 57 cannot go any longer. In the last few months I talked to quite a few people who either had no gap with a different health fund or were financially well of enough to not care.
I’ve been with the same fund for over 30yrs and would have payed tens of thousands over that time.
Do any members in this community have any insights?
Have you tried to access the Public Hospital system, you of course will need a referral to the Hospital from your GP. Then there may be some wait to be seen and prioritised. Sadly many wait far too long in the hope they can use their private health fund to get the procedure done and then when they find that they have not been able to save the finances and need to be seen quickly in an overloaded Public system, that there are long delays. If your need is considered high, you may be seen sooner than others. You also may get faster service in the Public Hospital if you are willing to use your Private Health membership to cover the bed and pharma cost, you need to mention this as part of your request to be seen.
BUPA provides the following advice on the out of pocket expenses with an average $1120 using members choice providers and a maximum of $3450.
In respect of the actual procedure requirements vary between patients. It may involve either some or all of the bones comprising the hip joint to be removed and replaced with either a metal or plastic prosthesis. Each specialist will want to make their own assessment and discuss their recommendations with the patient (aka customer). It’s not uncommon for medical specialists to offer slight differences in their recommendations.
I asked about that at my last admission and was told there is no difference in priority or ‘service’. Maybe it happens behind the curtains but not as publicly stated/admitted policy. Conclusion, using private health in a public hospital always benefits the hospital and only might benefit the insured patient - with no way to tell about the latter. For elective surgery there is a difference in that one picks their surgeon whose office arranges matters. In my limited experience the private system prefers private hospitals where/when available.
Yes, All of this is true, but under the cost assumptions third dot point “Your doctors are part of the Bupa Medical Gap Scheme” Yes they give out a big list of Dr’s but the catch is in the “Next Best Steps” #2 Find a specialist who is part of our Bupa Medical Gap Scheme. If they apply the scheme, you can reduce your out-of-pocket costs.
Which brings me back to the OP, you have to have to pay for a consultation before they’ll give costs. That’s a big IF.
Then there’s the other fees which are not covered.
Surgical assistant aprox $450 and Anesthetists aprox $800 bringing it up to the $4-5k range out of pocket.
To get an indicator of private costs and % of people without or with out of pocket costs
There are many variables in something like a total hip replacement. We’ve been warned it could be 2 to 5 days in hospital post-op, there’s physio, two pre-op consultations, two post op consultations, imaging before and after, home nurse etc. How long is a piece of string.
In response to your question, you will need medical codes from your surgeon to take to your insurance or Medicare. Here is other helpful related issues.
I also thought I would give fellow consumers the heads up when t comes to joint replacements and red flags to consider with your health fund and possible nickel metal reactions.
Last year 2022, I had two knee replacements scheduled and used private hospital and private health insurance to claim. Numerous issues arose and here are steps to consider when seeking joint replacement as follows:
Obtain quote from surgeon for medical costs and out of pocket expenses eg medications. Review your surgeon online with searches, consumer feedback and APRA search. Be clear about what level of qualifications they hold, what procedure and process the use in the operating room (ie robotic vs 3D vs manual). Realistic timeframe for recovery and recovery classes. What level of post surgical support they actually provide to patients.
Obtain clearance and written agreement from your health fund as to what they will cover including prosthetic appliance, hospital stay, aesthetics and theatre costs at the hospital where the surgeon performs their operations along with recovery program options. Also, get them to state what they won’t cover.
Determine if payments require you to pay hospital upfront and then claim from fund or whether account is directly billed from hospital to health fund and you pay the gap payment or excess amount. Need to do this weeks before you go into hospital.
Seek to have all your required operations in the same calendar year or 12 month period (depends on funds rules). This way you only pay one excess payment. Seek advice from your health professional whether this option is advisable.
If Health Fund advises the prosthetic is not listed on the Commonwealth Dept of Health’s Prosthetic List, see if there is one very similar or previous model with same components yet given a new name. Health Funds will claim they don’t cover items not listed on the Prosthetic list. Interesting this list is only determined by Commonwealth Health Committee who meet a few times a year and add few new items to the list and have long waiting period for listings. This Committee’s purpose is to determine whether the government can afford to add new items to Medicare Rebate and has nothing to do with private health insurers.
Private funds have no influence over Prosthetics List and use it as an excuse not to pay for peoples knee and hip replacements. The safety regulator of prosthetic devises is regulated by the Commonwealth Therapeutic Goods Association (TGA) with listing by either the company of the device or a local health specialist who intends to use the device. Private Health Fund should not rely on the Prosthetics List to determine what device to use. Private Health Insurers should rely on the Therapeutic Goods temporary or permanent prosthetics listing to determine the selection and safety of devices. If private health funds only use what the Australian Government use for prosthetic devices then you may as well get knee replaced under Medicare! Doesn’t this defeat the purpose of getting private health insurance in the first place!
Determine the level and costs for physiotherapy support available in hospital; as an out patients and privately in your local area for post surgery recovery. Check out Physiotherapy individual and group classes including hydrotherapy classes accessible in your local area. Recovery from operation at least 3 months and knee recovery takes 12-24 months. If you can afford private physiotherapy, then build up a relationship with one prior to operation either to avoid/delay the operation with muscle strength and weight loss or to get a baseline of your functioning and pre-operative exercise to aid recovery. Either way it will be a long journey of recovery to get full range and motion out of a new knee yet you can regain your mobility.
When nursing staff give you medication in those plastic cups - keep them as you will likely need them when you go home and have to continue medication. You can set them up like a Webster pack for daily dosing. Medication at home can be daunting experience when you have to take up to 7 different medications three times a day. When under the influence of pain medication one can experience brain fog and confusion with what tablets to take, when to step down and later cease.
Manage your pain, do you exercises, see your health professional for reviews and follow up. Get back to safely driving (if previously driven) and connecting with people.
If you have a suspected metal allergy ie Nickel then it will likely take you up to 12 months to get the skin test prior to the surgery. The test is not covered by health insurance nor Medicare. If you react to metal studs/buttons, belt buckles, wedding rings, metal necklaces, ear-rings, bra straps clips against your skin etc…Do get skin tested! The results are not pretty if your body rejects your new prosthetic and you have to sit in hospital with no knee while waiting for a new one! Note: Knee devices can only be replaced once!!! There are no government rules nor health insurance requirements for a person to obtain metal allergy skin test prior to prosthetic installment.
Welcome back @Firefly, I have edited your post as it was a copy of another topic you created. To keep the topics tidy, this one about joint replacement seems the best fit. Thank you for your post.
Thank you for the long list of items to consider and potentially discuss with the GP, Specialist, Health Fund etc. My partner has had knee replacement surgery for both knees. We found navigating many of the items in your suggested list relatively straight forward.
On the costs we received a concise explanation of all the expected costs from the orthopaedic specialist and anaesthetist, plus further advice on the other needs post op (physio) and hospital. These included clear statements of the allowances for the cover provided through Medicare and our chosen health fund. The greatest shock and unexpected cost was for the parking charges in the hospital car park.
Re point 10
Something to discuss with your GP and specialist. Also assuming there is some medical support one may be allergic to that group of metals. Allergen skin patch testing has a Medicare schedule item number. It seems an unusually long time to wait for a result. Orthopaedic surgeons are familiar with the risk and will select the prosthetic materials including Titanium alloys and ceramics as appropriate.
The process for my replacements was not clear cut and had many more loops to jump thru due to my health fund, my nickel allergy, my age. Where I live there is only one health professional who is considered credible by other medical professionals to undertake skin testing and hence the long wait time. My surgeon requested skin testing prior to taking on my case. I had to wait until I could not walk to access an operation. I did not elect for the Titanium/ceramic options as their longevity would not meet the distance and recommended to last for 15-20 years, I opted for a newer product by Zimmer Biometric Persona Knee - Ti-Nidium Knee made from titanium/Neodymium -the rare earth elements electric car are made with. This knee due to last 35 years and if all goes well it should last the distance of my life. Will check out the Medicare code for allergy skin patch testing.
I followed up suggested skin patch testing. Indeed Medicare rebatable item as follows:
Medicare Code: 12017
D1 - Miscellaneous Diagnostic Procedures And Investigations
9 - Allergy Testing
Epicutaneous patch testing in the investigation of allergic dermatitis using more than 25 allergens but not more than 50 allergens
Fee: $74.25 Benefit: 75% = $55.70 85% = $63.15
