Fees and Insurance

(Updated 5/22/2008)

VI. Explanation of Fees:

A. “In  network”  vs. “ out of network”

I do accept payments on your behalf from any insurance company. I will be happy to precertify 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.), if I am “out of network for your health insurance plan, please see section (c.) below.

B. Standard fee schedule

• Insurance discounts may be applicable. 
• This applies to all patients who are covered by insurance companies with which I have a contract.  I am “in network” for these plans. 
• You pay only what is required by your plan.  I receive the a 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.
• If I do not have a contract with your insurance company (I am “out of network” with your plan), you can choose to have me bill your insurance company the standard fee schedule and you agree to pay the difference later.  Or you may opt for prepayment according to a reduced prepayment fee schedule. (see section IIId.)

C. Discounted prepayment fee schedule

• Applies to Medicare, Medicaid, Tricare, 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.
• Any patient who has a private non-government insurance company for which I am “out of network” can choose to pay in advance according to this schedule and have us submit a bill to their insurance company for reimbursement.  We will be happy to assist you with this paperwork.  Any amount the insurance company reimburses us (up to the discounted prepaid rate) will be returned to you (see section IIId.).

D. Payment options for patients when I am “out of network” with your insurance carrier (primary hip or knee replacement procedures):

Plan A

• You pay the discounted Fee in advance:                                       $6000

• The standard fee is billed to your insurance carrier:                        $8000

• Any payment up to $6000 from your insurance carrier will be returned to you

• Your total payment:                                             $6000 – Insurance payment

• My total receipt:                                                                   $6000 – 8000

Plan B:

• Your down payment :                                                                     $2000
• Standard fee schedule bill to your insurance carrier:                         $8000

• Insurance company pays their required amount:                                     ?

• Any amount less than the remaining $ 6000 that is not paid by the insurance
   company will be billed to you

• Any payment over $6000 from your Insurance company will be returned to you

• Your total payment:                                               $8000 -insurance payment

• My total receipt :                                                                            $8000

Explanation:

As you can see from the above calculations, I am willing to accept a potentially lower total payment if I am paid in advance and don’t have to wait on payment from your insurance company.

You will probably pay less under plan A and will know that your payment to me for the operation will be $6000 or less.

E. Full Fee Schedule:
(The reduced schedule is approximately a 25 % discount and applies if you choose to pay in advance)

                                                                                          REDUCED   STANDARD

1. OFFICE VISIT:

A. New problem

1. Usual                                                                      $150                $188                                                       

  2.Complex                                                                 $200              $250

B. Follow up visit 
           1. Usual                                                                            $50                $63
           2.  Post-op (within 3 months)                                             $0                  $0
           3. Complex                                                                      $100               $125
           4.  Follow up with Lee Webb                                           $25                 $31
C.      Injections
           1. Injection or aspiration any joint                                      $50                $63

2. X-RAY
(50 per film / $63 per film)
Depending on the nature of the evaluation
 and whether right and/or left sides are being
 checked, 3-13 films may be required
(total equals number of films x $50 per film).

Typical examples are given:

1. Hip
1. New evaluation (#3)                                               $150                  $188
2. Follow up (one side #2)                                          $100                  $125
3. Follow up (two sides #3)                                        $150                  $188
2. Knee
1. New evaluation (one side #4)                                 $200                   $25
2. New evaluation (two sides #7)                               $350                   $43
3. Long alignment (view 1 side #3)                             $150                   $188
4. Follow up (one side #3)                                         $150                   $188
5. Follow up (two sides #6)                                       $300                   $375
3. Others

             Most of the areas evaluated  require two to three films:    $100 -150         $125-188
      

3. 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.

 A. Straight-forward surgery                                                   $6000                    $8000
    

1. First time total hip replacement, total knee replacement, partial knee replacement or hip
    surface replacement in most cases. 
2. Simple revision surgery            
3. Hip impingement surgery
    

B. Difficult surgery                                                                   $8000                    $10,000

1. Any of the above in severely obese (BMI greater than or equal to 35%) patients
    or patients with underlying difficult deformities
2. Usual revision surgery
    

C. Complex surgery                                                                 $10,000                  $12,500
               

1. Custom implants    
2. Extensive revisions   
   

D. Minor surgery

1. Hickman catheter removal                                             $1000                     $1250
2. Knee arthroscopy                                                         $3000                     $3750
   

E. Miscellaneous                                                                      $-Variable  

F. Assistant fee – a 25% First assistant fee has already been included in the above fees

G. Complications may require repeat surgery which will be billed separately. Revision surgery is more prone to complication. 
 

H. 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 and your choice of payment option. Office visits, injection, x-rays are payable at the time of service. 

• Credit card or Capital One financing accepted.
• Late payment will result in a 20% surcharge.

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