Replacements And Reconstructions: How To Decipher The Jargon

Most of us have experienced the frustration of comparing health insurance funds and policies, whilst trying to decipher the hospital jargon along the way. But for some, we have learnt the jargon the hard way and have experienced it firsthand.

Reconstruction vs Replacement: What’s the difference?

Reconstruction: A reconstruction is; in the scheme of things, more of a minor surgery in comparison to a replacement. A reconstruction is tailored to the type of tear or fracture you have, and usually involves a surgical procedure to stabilise and/or repair the affected area.

Replacement: A replacement, meanwhile, goes further. It generally involves replacing the joint with an artificial implant or prosthesis, varying for factors such as age, body structure and lifestyle.

In both scenarios, a hospital stay is required and the procedure will be performed by a specialist surgical team.

How do I know if I’m on the right health cover for replacements or reconstructions?

The literal jargon differs fund to fund and it can often be challenging working out the details and out-of-pocket expenses. At iSelect we’re here to help. Call us on 13 19 20 today to ensure you’ve got the right cover.

How to get reconstructions covered on your policy

Every surgery procedure has something called a Medicare Item Number, this is assessed and nominated by your specialist/surgeon. The numbers represent the exact procedure you require. It may not be a simple reconstruction, they may need to extract bone or tissue from somewhere else, which may require multiple item numbers based on your specific case – every case is different.
Reconstruction surgeries involving the jaw, spine, ankle and even things like bunions, generally require a higher level of basic cover. If your cover says “Only Hip and Knee”, it’s probably a good time to compare your health insurance as this might not cover everything you need.

Here are four simple steps to understand if you’re on the right cover for reconstructions:

1. Make sure your policy states in the inclusions that you are covered for, something along the lines of: Joint investigations and reconstructions. Remember to always check with your health fund before you book the surgery to make sure you know you’re covered.

2. Check the procedure is not listed as a restriction or exclusion. This could see you being treated as a private patient in a public hospital or not covered at all leaving you to navigate the public health system.

3. If your cover says you’re covered for knee or shoulder but excludes all other joint reconstructions or investigations – you may not be fully covered, remember every case is different. Sound too complicated? Call us on 13 19 20 and we can check your cover.

4. Make sure you have an appropriate level of hospital cover that provides sufficient cover for reconstructions. Look for a policy that states you’ll be covered for: All other in-hospital services where a Medicare Benefit Item Number is payable. This means as long as it’s medically necessary and has a Medicare Item Number (and of course isn’t restricted or excluded) you’ll be covered.

5. Be sure to check what wait periods may apply

How to get replacements covered on your policy

Replacement surgery typically requires a higher level of cover, either a mid or a top cover, and with that comes a higher premium. So we need to make sure you’re correctly covered and not wasting your money. Much like reconstructions you need to make sure you are covered for the right procedures.

Here are four simple steps to understand if you’re on the right cover for replacements:

1. Make sure your policy states that you are covered for : Hip, Knee and all other joint replacement and revisions.

2. Check the procedure is not listed as a restriction or exclusion. This could see you being treated as a private patient in a public hospital or not covered at all leaving you to navigate the public health system.

3. If you cover says you’re covered for Hip and Knee but excludes all other joint replacements and revisions – you may not be fully covered, remember every case is different. Sound too complicated? Call us on 13 19 20 and we can check your cover.

4. Remember to always check what wait periods may apply.

How much does my health insurance cover?

Medicare covers 75% of the fee for private hospital services listed by the Medicare Benefits Schedule (MBS)
Private health insurance will cover a minimum of 25% of the MBS fee and may cover some of the remaining costs. The specialist surgeon will advise you of any other out of pocket expenses prior to the procedure.
If you are concerned about needing a reconstruction or replacement, it’s worth seeking advice on appropriate policies as many basic or lower-level hospital cover policies could have tricky restrictions or exclusions. Compare health insurance policies now and find out if you’re on the right cover.

Can I minimise the cost of my surgery?

As well as hospital rooms and operating theatre fees to consider, you should check your surgeon and anaesthetist charges before you undergo any kind of hip replacement surgery. You should also request an informed financial consent from the surgeon. This will detail all out of the pocket expenses that will be incurred as a result of the surgery. Your health fund can advise if your surgeon and his team participate in their “Gap Cover” scheme.

How do I choose the right fund?

As there are so many registered health funds and policy combinations in Australia, when it comes to reconstructions and replacements we recommend you shop around to find the health fund and policy that best suits your needs. For instance, several private insurance policies offer extra cover for a range of options including non-surgical prosthesis and other ancillary services. You may also wish to consider a policy with generous cover for services you might need post-surgery, such as physiotherapy.

Want to know more?

Find out more about health insurance cover for hip reconstructions and replacement by comparing health insurance policies today.