Understanding Out-of-Pocket Costs for Orthopaedic Surgery at STAR Orthopaedics
Navigating the financial side of surgery can feel confusing, especially when you’re juggling Medicare, private health insurance, and surgeon’s fees. At STAR Orthopaedics, we aim to be clear, upfront, and transparent about costs so you know what to expect well before your operation.
How Orthopaedic Surgery is Funded in Australia
Most privately performed operations are funded by a combination of:
- Medicare rebate – the government contribution, based on the Medicare Benefits Schedule (MBS)
- Private health insurance – your health fund’s contribution, which varies by fund and level of cover
- Surgeon’s fee – the professional fee charged by your surgeon
- Other providers’ fees – such as the anaesthetist, assistant surgeon, hospital, and any prostheses or implants
Understanding Out-of-Pocket Costs for Orthopaedic Surgery at STAR Orthopaedics
What is a “Gap” Payment?
The gap is the difference between:
Total surgeon’s fee
minus
Medicare rebate + private health fund benefit
Because the official rebates are lower than AMA-recommended fees, a gap is common for most elective orthopaedic procedures in the private system.
At STAR Orthopaedics:
- For elective surgery, the expected out-of-pocket cost is clearly outlined before you book your operation
- For trauma and emergency cases, any out-of-pocket fee will depend on the item numbers used and what your insurer returns after the surgery has been billed
When There May Be No Gap
In some circumstances, you may not have an out-of-pocket cost for the surgeon’s fee, for example:
- Department of Veterans’ Affairs (DVA) patients (depending on eligibility and approvals)
- WorkCover or other workers’ compensation claims (when liability and funding are accepted)
- Motor vehicle accident insurance claims (once approved by the insurer)
Our team will help confirm your coverage and explain what applies in your situation.
When Payment is Required
To avoid financial surprises and to keep the process smooth:
- For elective surgery, surgeon’s gaps are usually payable prior to your operation
- For trauma or urgent surgery, gap payments (if applicable) are generally arranged after the health fund and insurer have processed the claim, once the final amounts are known
You will receive a written financial consent outlining:
- The item numbers planned
- The estimated surgeon’s fee
- The likely rebates from Medicare/your health fund
- The estimated out-of-pocket cost
We encourage you to review this carefully and ask any questions before signing.
Money should never be an awkward surprise on top of surgery
At STAR Orthopaedics, we are committed to:
- Providing clear, written quotes before elective procedures
- Answering questions about rebates and gap payments in plain language
- Working with you, your health fund, and insurers to minimise stress around billing
