Insurance and costs

The ranges below are planning budgets, not national averages, fee schedules or quotes. They describe plausible totals across different hospitals and settings. Revision prices are especially uncertain, and real costs can be lower or much higher.

• Allowed total is the negotiated price an in-network insurer and you pay together. It's usually far below the hospital's sticker price.
• Your 20% share assumes an 80/20 plan where your deductible is already met and you haven't hit your yearly limit. Plans vary a lot; some use copays instead.
• Self-pay is a negotiated cash estimate before any charity care, not the undiscounted sticker price.

Your out-of-pocket maximum caps what you pay in a plan year for covered, in-network care. Premiums, care your plan excludes, and most out-of-network charges usually don't count toward it.⁷

In plain terms: the whole episode is often in the $19,100–$46,000 range before insurance. With a typical 80/20 plan, your share is usually capped by your out-of-pocket maximum, which for many plans is a few thousand to around ten thousand dollars a year.

A revision runs roughly $31,300–$84,000 before insurance, and staged infection treatment, fracture repair, major bone grafting or a long stay can push it higher. Nobody can honestly give you a single cash price for a two-stage infection treatment; get a written quote for each step.

Approval for surgery isn't approval for everything. Check the surgeon and the exact facility, then anesthesia, imaging, equipment, therapy and home health. Approval for the operation doesn't automatically cover an inpatient stay, home IV antibiotics or a rehab facility.

Hospital or surgery center. A freestanding ambulatory surgery center (ASC) is for selected, healthier patients and is often cheaper. A hospital outpatient stay, overnight "observation" and a formal inpatient admission are three different things, billed differently, so a hospital quote isn't automatically an inpatient quote. Some revisions can be done as outpatient surgery, but infection, major bone loss, fracture or medical risk may need a hospital.²

Cash prices vary in what they include. One surgeon publishes self-pay knee replacement prices of $22,300 at a surgery center and $26,495 at a hospital, including the surgeon, anesthesia, facility and implant, with a one-night hospital stay if needed. Pre-op testing, prescriptions, equipment, travel and complications are not included.¹ That's one example, not a national average, and it says nothing about revision prices. Ask whether physical therapy, medications, cold therapy devices and follow-up visits are included.

Infection changes everything. Treatment may be a washout that keeps the implant, a one-stage exchange, or two operations: removing the implant and placing a temporary antibiotic spacer, then putting in a new joint weeks or months later. Antibiotics and monitoring can run between the two. Ask for a separate estimate for each step and whether each needs its own approval.² A price for a first replacement is not a price for an infected revision.

• Equipment. A walker or cane, a shower chair and toilet equipment, and optional cold therapy or compression devices. Ask whether a powered device is really needed, and whether it's rented, bought or covered. A basic set often runs about $100–$400.
• Home and travel. Rides, parking, a hotel for a companion, meals, childcare and help with shopping add up, especially if your surgeon is far away. Everyday help around the house is different from skilled home health care and you may pay for it yourself.
• Prescriptions. Check the cost of blood thinners and pain medication before surgery.
• Revision extras. If there's infection, price the IV antibiotics, line, nursing, supplies, blood tests and infectious disease visits separately. Ask about braces, weight-bearing limits and bone graft before agreeing to any cash package.

Lost income is often the biggest cost that never shows up on a bill. These are rough allowances for budgeting, not return-to-work rules. Get job-specific clearance from your team.

Knee recovery keeps improving for six to twelve months. With revision, bone healing, weight-bearing limits, infection and extra operations can stretch leave by months.²³

Ask HR early about short-term disability, family and medical leave, a gradual return, and keeping your health insurance while you're out.

"Approved" doesn't mean paid. Prior authorization, whether a service is a covered benefit, whether each provider is in network, and your cost-sharing are four separate questions. A revision may need a new approval even if the first surgery was approved. A complication isn't automatically excluded just because the first surgery was planned.

Out-of-network doctors at an in-network hospital. Anesthesiologists, radiologists and assistant surgeons may bill separately. Under the No Surprises Act, most people with private insurance are protected from surprise out-of-network bills for this kind of care at an in-network hospital or surgery center, and you generally can't be asked to waive that protection for anesthesia. The law doesn't erase your deductible or coinsurance, and it generally doesn't cover ground ambulances, though some states do.⁸

A hospital bed isn't the same as being admitted. "Observation" is outpatient care, even overnight. Ask each day what your status is. Original Medicare generally requires three inpatient days before it covers a skilled nursing facility, and observation days don't count.⁹¹⁰

"All-inclusive" rarely means everything. Bundles may leave out the implant, pre-op imaging, prescriptions, therapy or complications. A manufacturer's implant warranty isn't revision insurance; it may not pay the hospital, surgeon, anesthesia or rehab.

A cash price you pay outside insurance may not count toward your deductible or maximum, and a hospital's charity care may not cover independent doctors. Check both before paying.¹¹

First surgery. Insurers usually want X-rays showing advanced arthritis, pain or disability that limits daily life, exam findings, and a record of what you've tried first (medication, exercise or therapy, activity changes, a cane, injections) with dates and how it went. Medicare's local rules and private policies differ.⁴⁵

Revision. The request should explain what failed: loosening, wear, instability, stiffness, fracture, bone loss or infection, backed by imaging and, when appropriate, blood tests and a joint fluid sample. Pain alone needs investigating; it doesn't prove a revision will help or be covered. You shouldn't have to repeat months of physical therapy before treatment for infection, fracture or a mechanical failure; ask for the policy that fits your actual problem.⁴

1. Get one accurate description of the plan. The procedure and diagnosis codes, which side, the surgeon and facility, the proposed implant, expected inpatient or outpatient status, and the rehab plan. For a revision, what will be removed, kept or replaced, and whether it's one stage or two.
2. Call your insurer with that information. Are these doctors and this exact location in my network? How much is left on my deductible and out-of-pocket maximum? What are the rules for surgery, therapy, equipment, home health and prescriptions? When does my plan year reset? Write down the reference number.
3. Close any approval gaps. Get the authorization number, dates, codes and approved setting. Ask whether each revision stage, admission, home IV service and rehab stay needs its own approval. If denied, get the reason and policy in writing, ask your surgeon about a peer-to-peer review, and watch the appeal deadline.
4. Get written estimates. With insurance, ask for an estimate based on your current benefits. Without insurance (or if you choose not to use it), you have a federal right to a Good Faith Estimate from each provider that bills you: the facility, surgeon and anesthesia group each send their own.¹²
5. Clarify the bundle and deposit. Are implants, anesthesia, assistant surgeons, tests, an overnight stay, follow-up visits and rehab included? What happens if there's a complication, a cancellation or a transfer? What if the planned operation turns into a bigger one?
6. Ask before going out of network. If no suitable in-network specialist is reasonably available, ask your insurer for a network-gap exception and a single-case agreement, in writing from both the insurer and the provider, stating you'll pay in-network cost-sharing and won't be balance billed.

1. Ask for help before taking on debt. Ask the hospital's financial counselor about charity care, hardship programs, uninsured discounts and payment plans, even if you're insured. Nonprofit hospitals must have a written financial assistance policy.¹¹ Before using a credit card or medical financing, compare interest and deferred-interest terms.
2. Price the discharge plan. Confirm the pharmacy, equipment supplier, therapy clinic and any home health or IV provider are in network and approved before you use them.
3. Check your EOB against the itemized bill. An Explanation of Benefits isn't a bill. Match dates, procedures, side, network status, allowed amount and your share. Look for duplicates, denials and missing deposits. If something's wrong, ask for an itemized bill and a written hold on the disputed amount while it's reviewed.
4. Use the right protection. For a surprise bill that may break the No Surprises Act, contact the provider and insurer first, then file at cms.gov/medical-bill-rights or call 1-800-985-3059.⁸ If you're self-pay and one provider bills you at least $400 more than its Good Faith Estimate, you may be able to dispute it within 120 days of the bill.¹³
5. Keep everything in one place. Estimates, approvals, policy pages, assistance decisions, EOBs, receipts and call notes. Before paying a final balance, make sure insurance has finished processing and discounts and deposits are applied. For staged treatment, repeat this for each stage and each plan year.

• Which parts will be kept, swapped or removed, and is infection suspected?
• What are my weight-bearing limits and how much help will I need, including between stages?
• Write down: insurer reference number, authorization number, remaining deductible, remaining out-of-pocket maximum, written estimate, and plan-year reset date.

Download the full printable guide (PDF), with a fill-in worksheet.

This is general education, not a coverage decision or medical advice. Policies, prices and codes change; check them with your team and insurer before scheduling. See also finding the right surgeon.