Joint replacement surgery involves replacing a damaged joint with an artificial joint made of metal or plastic and is most commonly performed on knee or hips, but can also include shoulders, elbows, wrists, fingers, ankles and toes.
The most common reason to get a joint replacement is osteoarthritis but can also be needed due to a fracture, avascular necrosis (a disease that limits blood supply to the joint), trauma or injury; the aim of having a joint replaced is usually to relieve severe pain, return movement and increase quality of life to the patient when exercise programs and pain medications are no longer effective.
There’s nothing more personal than your health, and when it’s time to go to hospital, where you are treated can make a big difference to your experience… so, do you go Private or Public?
One of the biggest advantages of electing to be a private patient for your admission is the choice it gives you… you get to choose the Surgeon that treats you and where and when you have your treatment, which also means skipping the often very lengthy waiting lists of the public system.
We’ve put together the table below, to help you understand the difference between being a Private or Public patient, so you can make the best decision for you.
Private Patient in a | Private Patient in a | Public Patient in a |
|
|---|---|---|---|
Is there a waiting period? | Yes – 12 months for any pre-existing conditions and 2 months for all other conditions. Learn more about Waiting periods here | No. |
|
Can I choose my hospital? | Yes, depending on what hospitals your Specialist works out of. | Yes, depending on your Specialist and availability at the hospital. | Generally, No. |
How quickly will I be treated? | As soon as you and your specialist are ready. | As soon as you and your specialist are ready and there is a time available for your procedure at the hospital. | As soon as a time becomes available on the public waiting list. This could range from weeks to even years depending on the procedure you require |
Can I choose my Specialist? | Yes. | No. |
|
Will I get a private room | Yes, if one is available. | Yes, if one is available, but there’s likely to be out-of-pocket expenses. | Only if one is available to you, although it’s likely you’ll be in a shared ward. |
Will I have to pay an excess? | Yes – you’ll pay your excess according to your level of cover, once per person per calendar year. | No. |
|
Will I have to pay for my hospital accommodation? | No – As long as the surgery is included in your cover with Phoenix Health. | You will potentially have out-of-pockets. You are eligible for accommodation benefits applicable to your state | No. |
Will I have any additional fees? | Doctors’ fees above the Medicare Benefit Scheduled Fee (MBS) See Section 4.1, your hospital excess (if you have one), personal items like newspapers, TV and pharmaceuticals provided on discharge will be payable by you. | Likely none. |
|
It’s important that you know that it’s your right to choose where you’re treated and whether you want to be a private patient in a private hospital, a private patient in a public hospital or a public patient in a public hospital. Just because you hold private hospital cover does not mean you have to be a private patient when you go to a public hospital.
Why do public hospitals ask members if they would like to use their private hospital cover? Public hospitals ask patients if they would like to be admitted as a private patient because they are paid at a higher rate for the admission when they bill a private health fund, compared to what they would receive from Medicare and the Government for the same public admission.
But will I receive better treatment if I am a private patient? No. You’ll still receive the same treatment, you’ll get a private room if one is available, although it’s likely you’ll be in a shared ward. The time you’ll wait to receive treatment will be that same as if you were to be a public patient, as priority is given based on medical need.
Are there costs involved for me if I use my private cover in a public hospital? Yes, it’s likely that by using your private cover you’ll have to pay your hospital excess (where one applies to your cover). Check out Section 2.2 for more information on being a private patient vs a public patient.
How does it work if I’m admitted as a public patient? By electing to be a public patient in a public hospital, Medicare will fund your admission – putting less pressure on the premiums Phoenix Health charges its members; plus you’ll also not have any out-of-pocket expenses to pay towards your admission.
| Feeling pressured in a public hospital to be admitted as a private patient? Sometimes members have felt like they were pressured by a public hospital to use their private cover for their admissions. You need to know that it is your choice whether you want to stay a public patient, or if you want to elect to use your private cover. You are not required to provide the hospital with your private health insurance information. If you are ever unsure, get in touch with the Phoenix Health team. |
In-patient services are received whilst you’re admitted into hospital. If you’re admitted as a private patient, as long as the treatment you receive is included with your Hospital Cover, then you will be able to claim up to the Medicare Benefit Schedule Fee (MBS) (see Section 4.1 for more details). For example, if you’re having a knee reconstruction, when you go to hospital for your surgery, you’ll be admitted as an in-patient.
Out-patient services are treatments received outside of a hospital admission. Any treatments you receive as an out-patient are not claimable under private health. Out-patient services are generally claimable through Medicare.
| For example, any Doctors appointments in their rooms, or blood tests you have prior to your hospital admission will be done as an out-patient service and are not claimable through your private health. |
| Did you know… that if you ever need to go to the emergency room of a private hospital, any services you receive will be considered out-patient services and will not be claimable through Private Health Insurance. This includes if there is a facility fee charged – this will become your out-of-pocket cost. Learn more about Emergency Hospital visits here. |
As soon as you know you need to go to hospital, give us a call on 1800 028 817 and we can help you navigate your upcoming admission – there’s a lot of information and we’re here to help you!
When you get in touch we’ll:
- check to make sure your hospital policy includes cover for the treatment you require
- make sure you’ve served any relevant waiting periods
- tell you if you’ll have an excess to pay towards your hospital stay
- advise you know what to ask you surgeon, so you’ll have all the information you need
- walk you through how the claiming process will work, what you can (and can’t) claim for and how to submit any claims, and
- inform you of any Health Support Programs that are available to support you through your admission and or recovery
It’s our job to make your health insurance and hospital admission as easy as possible, so get in touch if you ever have any questions!
Yes, you can choose your own Private Hospital! Phoenix Health has agreements with 480 hospitals around Australia – so as long as your preferred hospital is on our list, you’ll be covered. It’s easy to check if the hospital of your choice is an Agreement Hospital, Click Here.
Yes, having the choice of who treats you is one of the biggest advantages of holding Private Health Insurance – after all its who you’re trusting with your health.
But how do you choose a Surgeon? Your GP may recommend one, maybe a friend has recommended someone, or you’ve found a Surgeon through your own research. If you’re still looking, you can use our Find a Provider tool to find a Surgeon in your local area.
You’ll be able to see if the Surgeon uses Access Gap Cover – which can reduce some of your out-of-pocket expenses for your surgery. See Section 4.3 for more information.
One thing to keep in mind is most private Surgeons work out of certain hospitals, so you’ll need to have a discussion with them about where they practice and if it’s the hospital you’ve chosen.
| Do you need to get a second opinion? Even if you’ve seen a Surgeon, if you’re not feeling comfortable with the Doctor, your diagnosis and treatment options or the costs quoted, get a second opinion! It happens more often than you’d think and is a good idea, so you can have all the information you need to make the right decision for you. |
So that you are able to have all the information you need, so you can make the right decisions for yourself, and so that your hospital claiming experience is as smooth as possible, we recommend asking your Surgeon these questions:
- What item numbers will you be using for my procedure?
- Will you participate in Access Gap for my procedure?
- Will any other Specialists – like the anaesthetist or an assistant surgeon etc. participate in Access Gap for my procedure? If unsure, can I have their contact details so I can get this information?
- Can you provide me with a full breakdown of fees for my treatment (also known as Informed Financial Consent)?
- Will I need a Medical Device (e.g. hip or knee joint) or Human Tissue product and what will be my out-of-pocket expenses?
- Will I need any other diagnostic tests before my hospital admission?
You can find these questions along with more tips in our downloadable guide, Going to Hospital, Navigating a Joint Replacement with Phoenix Health.
