Latest / The Total Knee Success Podcast: Your Essential Resource for Navigating Total Knee Replacement / Episode 111: The Knee Replacement Costs Nobody Warns You About, Part 1 (Before Surgery and on Surgery Day)

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Episode 111: The Knee Replacement Costs Nobody Warns You About, Part 1 (Before Surgery and on Surgery Day) · The Total Knee Success Podcast: Your Essential Resource for Navigating Total Knee Replacement

• 0:00
  A person who has a surgery in December and begins
• 0:02
  physical therapy in January may have expenses
• 0:05
  counted in two different plan years. Some employer
• 0:08
  plans use a different 12 -month period, so Diane
• 0:11
  asked her insurer for the exact date her deductible
• 0:14
  and out -of -pocket totals would start over.
• 0:18
  Are you ready to get back to what you love after
• 0:20
  knee replacement? The Total Knee Success podcast
• 0:23
  is your trusted guide with practical tips, evidence
• 0:26
  -based strategies, and no fluff. It's not personal
• 0:30
  medical advice, just solid education to help
• 0:32
  you manage pain, regain mobility, and get back
• 0:35
  to living the life you love. Let's dive in. Welcome
• 0:41
  back to the Total Knee Success Podcast. I'm Michelle.
• 0:45
  Diane had her knee replacement date on the calendar
• 0:47
  when a friend mentioned the separate anesthesia
• 0:49
  bill she had received after her own operation.
• 0:53
  Diane looked at the hospital estimate in front
• 0:55
  of her. It showed a large number. but she couldn't
• 0:58
  tell whether the anesthesiologist or surgeon
• 1:00
  was included. She wanted to know what the estimate
• 1:03
  covered, which questions to ask, and which costs
• 1:06
  might still appear. Learning more ahead of time
• 1:09
  could reduce surprises and take some pressure
• 1:12
  off the money side of surgery. This is part one
• 1:15
  of the knee replacement costs nobody warns you
• 1:17
  about. We'll follow our fictional person Diane
• 1:20
  through the expenses that can come up before
• 1:22
  surgery and on surgery day. Episode 112 will
• 1:26
  pick up after she gets home. By the end of this
• 1:29
  episode, you'll have a better idea of which costs
• 1:31
  to ask about before knee replacement and whether
• 1:34
  the surgical team, hospital, insurer, or employer
• 1:37
  is the right place to get each answer. Having
• 1:40
  those questions ready can replace some of the
• 1:42
  unknowns with the information you can use. Diane
• 1:45
  started with the schedule from her surgical team.
• 1:48
  It included a medical visit and blood work before
• 1:50
  surgery. Her team told her which tests they wanted.
• 1:53
  and she called her insurer to ask how those services
• 1:56
  would be covered. She checked whether the lab
• 1:58
  was in her insurance network, whether she would
• 2:00
  have a copay for the visit, and whether the blood
• 2:03
  work would be billed separately. Those answers
• 2:05
  helped her identify costs that could appear before
• 2:08
  the surgery bill. Your schedule may include different
• 2:12
  appointments or tests. Use the list from your
• 2:14
  own surgical team and ask where each service
• 2:17
  will take place. A hospital, an independent laboratory,
• 2:20
  and a doctor's office may bill separately even
• 2:23
  when the appointments are all a part of preparing
• 2:25
  for the same operation. The office that schedules
• 2:29
  the service can tell you where it will happen.
• 2:31
  Your insurer can explain how your plan covers
• 2:34
  that location and provider. Prehab physical therapy
• 2:38
  was another possibility. Diane's surgeon recommended
• 2:41
  a few visits before surgery so she could learn
• 2:43
  what to expect, review exercises intended to
• 2:46
  improve her muscle activation and knee motion.
• 2:49
  Practice using a walker and learn safety techniques
• 2:52
  for the first few days at home. Before scheduling,
• 2:55
  she asked her insurer whether she needed a referral
• 2:57
  or advanced approval, whether the therapist was
• 3:00
  in her network, and what she would pay for each
• 3:03
  visit. She also asked about the number of physical
• 3:06
  therapy visits her plan allowed. Some plans place
• 3:10
  limits on visits during a benefit year. If your
• 3:12
  plan does, find out whether visits before surgery
• 3:15
  count toward the same limit as the visits you
• 3:18
  may need afterward. Your surgical team can tell
• 3:21
  you whether prehab is part of your plan, and
• 3:24
  your insurer can explain how those visits are
• 3:26
  covered. The knee replacement game plan goes
• 3:29
  much further into preparing for surgery. It can
• 3:32
  help you organize your questions, learn what
• 3:34
  to expect, prepare for the first few days at
• 3:37
  home, work on strength and knee motion, and become
• 3:40
  familiar with the equipment and safety techniques
• 3:42
  you may use. I'll include a link in the show
• 3:45
  notes where you can learn more about the book.
• 3:48
  Next, Diane looked at the equipment and supplies
• 3:51
  on her surgery list. A walker and shower chair
• 3:54
  were the two larger items. Her walker was borrowed,
• 3:57
  so she checked its height and condition with
• 3:59
  her healthcare team. That was a good step because
• 4:02
  an older walker may need new rubber tips, tightened
• 4:05
  hardware, or a height adjustment. A new walker
• 4:08
  also needs to be assembled correctly and fitted
• 4:11
  before surgery. She would probably buy or borrow
• 4:15
  the shower chair herself, so she measured the
• 4:17
  shower and checked which style would fit. Diane
• 4:20
  already owned reusable ice packs and had pillows
• 4:23
  and a firm cushion she could use to support her
• 4:26
  leg in the position recommended by her surgical
• 4:28
  team. Looking at what she already owned kept
• 4:31
  her from buying a package filled with items she
• 4:34
  didn't need. Your list may be shorter or longer.
• 4:38
  Before paying for equipment, ask three questions.
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  Does my team want me to have this? Will the facility
• 4:44
  provide or arrange it? Does my insurance cover
• 4:47
  it? Episodes 109 and 110 go further into equipment
• 4:51
  and product choices. For today, we're counting
• 4:54
  the purchases that may become part of your pre
• 4:57
  -surgery budget. Once Diane saw the full schedule,
• 5:00
  she could see where transportation might add
• 5:03
  another expense. Her blood work, medical visit,
• 5:05
  and prehab physical therapy were at different
• 5:07
  locations. Several trips could mean gas, parking,
• 5:11
  or time away from work. Diane chose to keep track
• 5:14
  of the expenses that would affect her plans.
• 5:16
  You can do the same if those details are useful
• 5:19
  to you. Diane's brother offered to drive her
• 5:22
  on surgery day. She asked the surgical team what
• 5:25
  the facility required for transportation and
• 5:27
  whether someone needed to stay with her after
• 5:29
  discharge. Then she shared those instructions
• 5:32
  with her brother. With the appointments, supplies,
• 5:35
  and ride arranged, she returned to the hospital
• 5:37
  estimate and her friend's question about anesthesia.
• 5:41
  The estimate included a phone number, so Diane
• 5:44
  dialed it. If your estimate has no contact number,
• 5:47
  call the hospital's main number and ask for the
• 5:50
  office that prepares cost estimates for patients.
• 5:53
  The office may be called Patient Financial Services
• 5:55
  or the Billing Office. Tell them which surgery
• 5:58
  is scheduled, where it will take place, and what
• 6:01
  estimate you received. Then ask someone to explain
• 6:04
  which services the number covers. Her first question
• 6:08
  was direct. Does this include the hospital, the
• 6:11
  surgeon, and anesthesia? The estimate covered
• 6:13
  the hospital's services. Diane already had the
• 6:16
  surgeon's office information. The hospital representative
• 6:19
  gave her the contact information for the anesthesia
• 6:22
  group so she could ask about that charge. She
• 6:25
  also asked whether laboratory work, imaging,
• 6:28
  or other professionals might bill separately.
• 6:31
  By the end of the call, she knew what the hospital
• 6:33
  estimate described, and where to ask about the
• 6:36
  remaining pieces. Since 2021, hospitals in the
• 6:40
  United States have been required to post information
• 6:42
  about their prices. The Centers for Medicare
• 6:45
  and Medicaid Services oversees that requirement.
• 6:48
  You may see a tool on the hospital website labeled
• 6:51
  Price Transparency or Cost Estimator. It can
• 6:54
  help you find the hospital's listed prices. For
• 6:57
  Diane, calling the hospital and requesting an
• 7:00
  estimate for her scheduled procedure was easier
• 7:02
  than sorting through the website. Either approach
• 7:05
  can help you identify what the figure includes.
• 7:08
  The hospital estimate was one part of the answer.
• 7:11
  Her insurer could explain how her benefits applied
• 7:14
  and what share she might owe. Diane called with
• 7:17
  the written estimate, the name of the procedure,
• 7:20
  and the names of the surgeon, hospital, and anesthesia
• 7:22
  group. That gave the insurance representative
• 7:25
  specific information to check. She began by asking
• 7:29
  whether each provider and the facility were in
• 7:31
  her plan's network. Then she asked how much of
• 7:34
  her deductible remained for the year. A deductible
• 7:37
  is the amount a person may pay toward certain
• 7:39
  covered services before the insurance plan begins
• 7:42
  sharing those costs. She also asked whether any
• 7:46
  services carried a set copay or coinsurance,
• 7:49
  which is a percentage of the allowed charge.
• 7:52
  The out -of -pocket limit was another number
• 7:54
  to check. For covered in -network care, the deductible,
• 7:58
  copays, and coinsurance may count toward the
• 8:01
  annual limit. Once the limit is reached, a plan
• 8:04
  will generally pay the covered in -network costs
• 8:07
  for the rest of the plan year. Premium services
• 8:10
  the plan does not cover and many out -of -network
• 8:13
  charges generally sit outside that limit. Diane
• 8:16
  asked the representative to apply those rules
• 8:18
  to her own plan and scheduled surgery. You should
• 8:22
  always get information for your individual plan
• 8:25
  because plans vary. She also checked when her
• 8:29
  plan year started over. Many plans run from January
• 8:32
  through December. Under that kind of plan, the
• 8:35
  deductible and out -of -pocket total start again
• 8:37
  in January. A person who has a surgery in December
• 8:40
  and begins physical therapy in January may have
• 8:43
  expenses counted in two different plan years.
• 8:47
  Some employer plans use a different 12 -month
• 8:49
  period, so Diane asked her insurer for the exact
• 8:51
  date her deductible and out -of -pocket totals
• 8:54
  would start over. There were several figures
• 8:56
  to keep straight, so she noted whom she spoke
• 8:59
  with. and what each person said. A trusted friend
• 9:02
  or family member can listen with you or take
• 9:04
  notes if you'd like another set of ears. You
• 9:07
  can also ask the insurance representative to
• 9:09
  slow down, repeat a figure, or apply the explanation
• 9:13
  to your scheduled surgery. If the hospital and
• 9:17
  insurer give you different estimates, ask which
• 9:19
  services each figure includes. Check whether
• 9:22
  both are using the same surgeon, facility, anesthesia
• 9:25
  group, and network information. One estimate
• 9:28
  may cover the hospital only, while the other
• 9:31
  includes a broader set of services. Finding that
• 9:34
  difference can make two numbers much easier to
• 9:36
  reconcile and understand. By now this may sound
• 9:40
  like a lot of phone calls, and I think it is.
• 9:43
  Start with the estimate you already have and
• 9:45
  make one call at a time. Each call can give you
• 9:49
  a better idea of what one number covers and which
• 9:51
  questions come next. Surprising medical bills
• 9:55
  can be quite upsetting, knowing which costs may
• 9:57
  appear and whom to call about them can make the
• 10:00
  financial side feel a little less overwhelming.
• 10:04
  Diane's friend had specifically mentioned anesthesia,
• 10:07
  so she asked about federal billing protections
• 10:09
  as well. The No Surprises Act has provided certain
• 10:13
  protections in the United States since 2022.
• 10:17
  For many people with private insurance, it limits
• 10:19
  extra out -of -network charges for covered anesthesiology
• 10:23
  services received at an in -network facility.
• 10:26
  You may still owe the in -network deductible,
• 10:28
  copay, or coinsurance that applies under your
• 10:31
  plan. These protections depend on the type of
• 10:34
  coverage and care. Medicare, Medicaid, TRICARE,
• 10:37
  and other programs have their own billing protections.
• 10:41
  Diane asked her insurer how the rules apply to
• 10:43
  her scheduled facility and anesthesia services.
• 10:47
  If a later bill seems inconsistent with those
• 10:49
  protections, contact the insurer and the provider
• 10:52
  billing office and ask them to review it before
• 10:55
  you pay. If you're uninsured or plan to pay without
• 10:59
  using insurance, ask the provider or facility
• 11:01
  for a good -faith estimate before scheduled care.
• 11:05
  Federal rules generally require an estimate in
• 11:07
  that situation. Ask which providers and services
• 11:11
  it covers and whether pre -surgery appointments
• 11:14
  or later physical therapy will be estimated separately.
• 11:18
  Keep the estimate with your paperwork. If one
• 11:21
  provider's bill is at least 400 above the provider's
• 11:23
  good -faith estimate, federal rules may give
• 11:26
  an uninsured or self -pay patient a way to dispute
• 11:29
  it. I'm not an insurance specialist. I want to
• 11:32
  make sure you ask questions if you need to better
• 11:35
  understand your individual costs and coverage.
• 11:38
  The episode article includes links to the official
• 11:41
  federal pages where you can read the eligibility
• 11:44
  requirements and dispute process. This is not
• 11:47
  a comprehensive discussion, and you may need
• 11:49
  more information. By this point, Diane had the
• 11:53
  hospital estimate, information from her insurer,
• 11:56
  and contact details for the offices that could
• 11:58
  estimate separate charges. Some final numbers
• 12:01
  were still unavailable. She knew which costs
• 12:04
  might appear. what the existing estimates covered,
• 12:07
  and where to ask about the remaining questions.
• 12:10
  That was the point of the work. The money side
• 12:13
  felt less like one giant unknown, and she could
• 12:16
  spend less energy wondering what she might have
• 12:19
  missed. Diane began figuring out what was going
• 12:23
  to be happening with work by contacting human
• 12:25
  resources because leave forms often need to be
• 12:29
  completed before surgery. She already knew how
• 12:32
  much paid time off she had and that her employer
• 12:34
  offered short -term disability coverage. She
• 12:37
  needed the details, when payments could begin,
• 12:39
  what percentage of her usual income the benefit
• 12:41
  paid, whether there was a waiting period, and
• 12:44
  when the forms were due. Next, she asked how
• 12:47
  paid time off, short -term disability, and family
• 12:50
  and medical leave work together under her employer's
• 12:53
  policies. The Federal Family and Medical Leave
• 12:56
  Act may provide job -protected leave for eligible
• 12:59
  employees. The leave itself is generally unpaid.
• 13:03
  An employer may allow or require paid time off
• 13:06
  to run during the same period, and short -term
• 13:08
  disability may replace part of a person's income
• 13:11
  if the employer's plan covers it. For eligible
• 13:15
  employees with group health insurance through
• 13:17
  work, that coverage generally continues on the
• 13:19
  same terms during family and medical leave. The
• 13:23
  employee usually continues paying the same share
• 13:25
  of the insurance premium. Diane asked Human Resources
• 13:29
  how she would make that payment while she was
• 13:31
  away from work and when every form was due. Make
• 13:34
  sure you check for your individual circumstances.
• 13:38
  The episode article includes links to the Department
• 13:40
  of Labor pages with the official Family and Medical
• 13:43
  Leave Act requirements. Your employer's Human
• 13:46
  Resources or Benefits office can explain how
• 13:49
  paid time off, short -term disability, insurance
• 13:52
  premiums, and leave work together under your
• 13:55
  specific plan. With those answers, Diane could
• 13:58
  estimate her income while she was away. The return
• 14:01
  to work date could be addressed later with her
• 14:03
  health care team and employer based on her job
• 14:05
  and how she was doing after surgery. By surgery
• 14:09
  day, Diane knew about the possible charges for
• 14:11
  blood work, prehab, equipment, and the operation.
• 14:14
  She understood her employer's leave process and
• 14:17
  had a better estimate of her income while she
• 14:20
  was away. A few figures could still change, but
• 14:24
  she knew which questions remained. and whom to
• 14:26
  call. That preparation reduced some of the uncertainty
• 14:29
  and helped the money side feel a little less
• 14:32
  stressful. If you're planning knee replacement,
• 14:35
  start with the information already in front of
• 14:37
  you. Look at the appointments and supplies from
• 14:39
  your surgical team. Ask the hospital what its
• 14:42
  estimate covers. Ask your insurer how your benefits
• 14:45
  apply. Check the leave and pay information from
• 14:49
  your employer. Take the calls one at a time and
• 14:52
  ask someone you trust to listen or take notes.
• 14:54
  if you think that would help. This episode, it's
• 14:58
  for education. Your surgical team directs your
• 15:00
  care, and the hospital insurer and employer can
• 15:03
  confirm the charges and benefits that apply to
• 15:06
  you. If you want more help preparing for knee
• 15:09
  replacement, the Knee Replacement Game Plan covers
• 15:11
  the questions, education, home prep, movement,
• 15:15
  and safety planning that can help you feel ready
• 15:17
  for surgery and the first days afterward. You'll
• 15:20
  find a link in the show notes where you can learn
• 15:21
  more about it. In episode 112, we'll follow Diane
• 15:25
  home and look at physical therapy, prescriptions,
• 15:28
  equipment, and help around the house. Thanks
• 15:31
  for joining me. I'm Michelle, and this has been
• 15:33
  the Total Knee Success podcast. This podcast
• 15:39
  is for educational purposes only. Discover more
• 15:43
  at TotalKneeSuccess .com. And be sure to subscribe
• 15:46
  and share, because every step forward takes you
• 15:49
  closer to living the life you love.