What your plan covers —
in plain language.
This table reflects general coverage patterns for our most common procedures across major plan types. Coverage details vary by your specific plan — that's why we verify yours before you schedule.
| Procedure | HMO Referral-based | PPO Flexible network | Medicare Parts A & B | Medicare Adv. Private plan | Workers' Comp Injury coverage |
|---|---|---|---|---|---|
Arthroscopy Knee or shoulder scope | ✓CoveredReferral required | ✓CoveredAfter deductible | ✓Covered120% after Part B deductible | ~Varies2Check plan cost-sharing | ✓CoveredIf work-related injury |
Total Knee ReplacementCommon Full knee joint replacement | ✓CoveredPre-auth required | ✓CoveredIn-network rate applies | ✓Covered1Part A if inpatient; Part B if outpatient | ◐Partial2Prior auth typically required | ✕Not CoveredNot covered unless work-related |
Rotator Cuff Repair Shoulder tendon surgery | ✓CoveredSpecialist referral needed | ✓CoveredAfter deductible & co-pay | ✓Covered120% coinsurance applies | ✓Covered2Network restrictions apply | ◐PartialCase-by-case basis |
Labral Tear Repair Hip or shoulder cartilage repair | ◐Partial3Medical necessity review | ✓CoveredWith imaging documentation | ◐Partial1Coverage depends on diagnosis | ~Varies2Plan-specific prior auth | ~VariesRequires injury documentation |
Fracture Fixation Surgical repair of broken bone | ✓CoveredEmergency prior auth | ✓CoveredStandard coverage | ✓Covered1Standard Medicare rates | ✓Covered2Typically covered; verify network | ✓CoveredIf workplace injury |
Physical Therapy Post-surgery rehabilitation | ◐PartialVisit limits may apply | ◐Partial3Co-pay per visit | ✓Covered1Part B covers; cap may apply | ~Varies2Check your Evidence of Coverage | ✓CoveredAs prescribed by physician |
Imaging (MRI/X-Ray) Diagnostic scans before surgery | ✓CoveredIn-network facility required | ✓CoveredOut-of-network costs more | ✓Covered120% after Part B deductible | ✓Covered2Prior auth for MRI common | ✓CoveredAs ordered by treating physician |
This table shows general patterns. Your actual benefits depend on your specific plan.
Verify My Coverage — FreeWe call within one business day · No cost, no commitment
"The question I hear most often is: 'Will I get a surprise bill?' The honest answer is — not if you work with us first. We've been doing this long enough to know where the surprises hide."
From insurance card
to clear cost estimate.
Most patients have never hit their deductible before. Here's exactly what happens when you ask us to verify your coverage — step by step, in plain English.
You give us your insurance card
You provide your insurance card and a brief description of the procedure you're considering. That's it. We handle everything from here.
We accept cards from all 14 major payers. If you're not sure which plan you have, we can look it up using your member ID.
We contact your insurance company
Our team calls your payer's provider line — not the member line — to get the exact numbers that apply to your procedure. We ask about deductibles, out-of-pocket maximums, co-insurance, and any facility fees.
We speak the same language as the insurance reps. We know which questions to ask to avoid surprises later.
We submit prior authorization (if required)
If your plan requires a prior authorization — and most do for surgery — we submit it with the clinical documentation your surgeon has already provided. We track it daily.
Our 96% first-submission approval rate means most authorizations come back approved without a back-and-forth. When they don't, we appeal immediately.
You receive a written cost estimate
We send you a clear, plain-language summary: what your insurance will pay, what you'll owe, and when. No asterisks that lead nowhere. No "amounts may vary."
The estimate breaks down the surgeon fee, facility fee, and anesthesia separately — because those often come from different billing entities.
We're here when the EOB arrives
When your Explanation of Benefits arrives in the mail, it can look alarming. Call us. We'll read it with you, explain what "contractual adjustment" means, and flag anything that doesn't look right.
Billing errors are more common than most patients realize. We catch them before they become collections.
"Nobody should delay a knee replacement because they're afraid of the bill. My job is to find a path that works — whether that's a payment plan, a financing option, or a hardship adjustment. Ask me anything."
Surgery shouldn't wait
because of a billing question.
We offer three paths depending on your situation. No judgment — every patient's financial picture is different.
No-Interest Payment Plan
Spread your patient responsibility over 6 or 12 months with zero interest, set up before surgery.
- Available for balances over $500
- Automatic monthly payments from checking or credit card
- No credit check required for amounts under $2,500
Extended Financing
Third-party medical financing for 18–36 month terms. Subject to credit approval.
- Offered through CareCredit and Prosper Healthcare Lending
- Promotional 0% APR periods available
- Apply same-day — decisions in minutes
Hardship Assistance
Income-based reduction or waiver of patient balances for qualifying patients.
- Requires financial disclosure form
- Sliding scale based on federal poverty guidelines
- Decisions made in-house — no third-party review
Questions patients ask us every day
Your deductible is the amount you pay out-of-pocket before insurance starts sharing costs. For example, if you have a $3,000 deductible and haven't had other medical bills this year, you'll likely owe the first $3,000 of your surgery cost. We check your year-to-date deductible status when we verify your benefits — so you'll know exactly where you stand.
A co-pay is a flat fee (e.g., "$40 per specialist visit"). Co-insurance is a percentage (e.g., "you pay 20% of the allowed amount"). Most surgical procedures involve co-insurance, not co-pays. Your written estimate from us will specify which applies and what dollar amount that translates to for your specific procedure.
No, and this trips up many patients. Medicare Advantage is a private plan that replaces Original Medicare. It may have lower premiums but often requires prior authorization for surgery and has narrower networks. We verify Medicare Advantage benefits separately because the rules differ significantly from plan to plan.
We appeal. Our team reviews every denial within 48 hours, identifies the reason (wrong code, missing documentation, network issue), and submits a corrected claim or formal appeal. We don't send a patient bill until we've exhausted insurance options. You won't hear from collections before you hear from us.
Let us pull your file
and walk you through it.
Two ways to get answers. Choose the one that fits where you are in your decision.
We'll call you within one business day
A member of our billing team — a real person, not a chatbot — will call to walk through your specific benefits and give you a written cost estimate.
- Your deductible status (how much you've met)
- Your out-of-pocket maximum
- Co-insurance for your specific procedure
- Whether prior auth is required
- Estimated patient balance