Cost of shoulder surgery
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Expert tips for health insurance for shoulder surgery
Our health insurance expert, Steven Spicer, has some helpful tips for finding the right health insurance for your needs.
Steven Spicer
Executive General Manager – Health, Life & Energy
Level of cover
With so many options available, you may wonder where to start when choosing your next private health insurance policy. Consider your health needs, family history and potential future requirements. Keeping these details in mind can help you get the coverage you need and avoid paying for inclusions you won’t use.
Cheaper isn’t always better
While it might be tempting to choose the policy with the lowest premiums, this could come at the cost of the coverage you’ll need. Instead of sacrificing inclusions, consider increasing your excess to lower your overall costs.
Compare your policy regularly
Been a while since you’ve looked over your policy? As we go through life, it’s worth regularly checking your policy to make sure it’s still the right cover for you. You may find you have inclusions you no longer need or that something you’ll likely need in the future isn’t covered under your current policy.
What is shoulder surgery?
Shoulder surgery is a medical operation, usually performed by an orthopaedic surgeon, which helps repair the bones, joints and/or ligaments in the shoulder.1 The need for shoulder surgery can be due to a number of reasons, including:1,2,3
- Wear and tear due to age
- To help with arthritis
- Rotator cuff tears
- Injury
- Ongoing shoulder pain
- Decreased mobility
- Help find the cause of pain.
While surgery should result in less pain and better function, your shoulder may not return to its pre-injury/damaged condition.
Common types of shoulder surgery
Shoulder replacement surgery
Shoulder replacement is an orthopaedic surgery that removes damaged portions of bone and replaces them with artificial parts (made of plastic and metal).1 This procedure can be necessary for arthritis or severe sports injuries.
Rotator cuff repair
Rotator cuffs can be damaged by sudden impact, lifting something too heavy or wear and tear due to aging and genetic factors.2 Rotator cuff repair can be performed by keyhole surgery or open surgery.
Synovectomy of shoulder
A keyhole surgical procedure removing the membrane from the shoulder joint. Synovectomy can help decrease pain and improve mobility in your shoulder.
Shoulder arthroscopy
Arthroscopy is a keyhole surgery that involves inserting a thin tube with a camera into the shoulder through a small incision.3 This procedure can diagnose the cause of problems and carry out various treatments.
Are there any alternatives to shoulder surgery?
Your doctor/specialist will likely want to try a few alternative treatments before suggesting shoulder surgery.1 This includes simple painkillers such as ibuprofen and steroid injections to help reduce stiffness. Seeing a physiotherapist or receiving other outpatient treatments may be recommended; physiotherapy can be covered by extras cover.
Once these treatments become less effective, shoulder surgery will be considered.
What does shoulder surgery cost?
The cost of your shoulder surgery will come down to several factors, including:
- Type of procedure
- Your choice of specialist
- Where you have the procedure
- Any complexities that arise during your surgery.
Below are the median costs for different types of shoulder surgeries. These prices are intended as a rough guide and your procedure may differ in total costs.
| Type of procedure | Medical Benefits Schedule item number(s) | Typical specialist fees | Median amount of specialist fees covered by Medicare | Median amount of specialist fee covered by health insurer | Median out-of-pocket cost for patients | Additional hospital fees (including accommodation, theatre fees) |
|---|---|---|---|---|---|---|
| Shoulder replacement | 48918 | $5,700 | $2,100 | $1,900 | $1,000 | $18,000 |
| Synovectomy of the shoulder | 48954 | $3,400 | $1,200 | $1,200 | $550 | $4,800 |
| Shoulder reconstruction or repair, including rotator cuff repair |
48960 48909 48906 |
$3,300 | $1,200 | $1,100 | $790 | $5,900 |
| Arthroscopic coracoacromial | 48951 | $3,400 | $1,200 | $1,100 | $680 | $5,200 |
|
Source: Australian Government Department of Health and Aged Care: Medical Costs Finder. Accessed 2024.4,5,6,7 These figures are current as of November 2024. |
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Does private insurance cover shoulder surgery?
Your private health fund may cover shoulder surgery, depending on your policy and its inclusions. Most shoulder surgeries are considered elective surgeries, so you’ll need the right level of hospital cover to make a claim. Depending on your procedure, your shoulder surgery will fall under the category, or a combination of categories, including ‘joint reconstructions’, ‘bone, joint and muscle’ and ‘joint replacements’.
There are many benefits to being treated as a private patient at a private hospital, including:
- Avoiding public hospital waiting lists
- A choice of specialist and clinic
- Opportunity to have a private room (subject to availability).
Remember, when you take out hospital insurance for the first time or upgrade your policy, you may have to serve a waiting period before you can make a claim. Usually, there’ll be a 2 month waiting period for new conditions and 12 months for pre-existing conditions however, there are some exceptions.
Does Medicare cover shoulder surgery?
Medicare can cover your costs for shoulder surgery, provided you go through a public system. However, the issue with having a procedure performed through the public hospital system is you’ll be put on a waiting list. Depending on where you live and the length of the list, you could end up waiting months until you receive treatment. You also won’t have much say on who performs your surgery and where the procedure takes place.
When you are treated through the public system, both Medicare and your health fund will contribute towards the cost of your procedure.
Meet our health insurance expert, Steven Spicer
As the Executive General Manager of Health, Life and Energy, Steven Spicer is a strong believer in the benefits of private cover and knows just how valuable the peace of mind that comes with cover can be. He is passionate about demystifying the health insurance industry and advocates for the benefits of comparison when it comes to saving money on your premiums.
1 Total Shoulder replacement – Health Direct. Accessed November 2024.
2 Shoulder surgery (rotator cuff) – Health Direct. Accessed November 2024.
3 Arthroscopy of the shoulder – Health Direct. Accessed November 2024.
4 Medical Costs Finder – Shoulder replacement. Accessed November 2024.
5 Medical Costs Finder -Synovectomy of the shoulder. Accessed November 2024.
6 Medical Costs Finder – Arthroscopic coracoacromial. Accessed November 2024.
7 Medical Costs Finder – Shoulder reconstruction or repair, including rotator cuff repair. Accessed November 2024.
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