Alexander S. McLawhorn, MD, joint reconstruction specialist serving patients in Manhattan and Stamford, currently accepts the following insurance plans:
- Aetna
- BCBS Anthem Gatekeeper Individual Network
- BCBS Federal
- BCBS Anthem of NY (formerly Empire)
- BCBS Horizon
- BCBS Anthem of CT
- Cigna
- Connecticare (not through Access Health CT)
- EmblemHealth GHI
- EmblemHealth HIP
- EmblemHealth Select Care
- The Empire Plan / NYSHIP
- Oxford
- UnitedHealthcare
- UnitedHealthcare Compass
As of July 1, 2024, Dr. McLawhorn opted out of the Medicare program.
If your particular insurance plan is not listed above, you may still have coverage, subject to the availability of ‘out-of-network’ benefits. Please do not hesitate to contact our office if you have questions regarding your insurance coverage.
International patients and patients without out-of-network benefits may call the office to discuss specific fees for services such as office visits and surgery. Dr. McLawhorn offers a fee schedule for his services that is simple, fair and transparent.
I have Medicare Part B insurance. What does it mean that Dr. McLawhorn has opted out of the Medicare program?
If you elect to have your care with Dr. McLawhorn, neither he nor you can submit claims for his professional services to Medicare or to any other program receiving money from Medicare (e.g., a Medicare Advantage plan). You agree to pay fees set by Dr. McLawhorn for his services. You pay these fees to Dr. McLawhorn prior to him providing services, such as office visits and surgery, to you. You may not submit claims for his fees to Medicare or any other Medicare-funded insurance for reimbursement.
Importantly, for complex services such as surgery, Medicare will cover all other usual services except for Dr. McLawhorn's professional fee. Medicare will cover services such as the hospital stay, imaging, anesthesia, implants, medicines, and other ancillary services as it would if you had surgery with a Medicare-participating surgeon.
Why did Dr. McLawhorn opt out of the Medicare program?
Dr. McLawhorn made this decision voluntarily but with great difficulty and not without significant contemplation. This decision does not mean that he is excluded from caring for Medicare patients. To the contrary, he believes that this decision will allow him to prioritize better the needs of his patients and his practice's commitment to providing the best possible hip and knee replacement care. Given continual cuts to Medicare reimbursement for hip and knee replacement procedures, he felt he could no longer sustain the type of practice that he endeavors to run and provide the care his patients expect to receive.
Dr. McLawhorn does not participate in my insurance plan. What are his typical fees?
Dr. McLawhorn has created a fee schedule for his services that is simple, fair and transparent. These fees are based upon the feedback of many patients and their perception of the value of the care they received from Dr. McLawhorn. You may call the office to discuss specific fees for services such as office visits and surgery. Dr. McLawhorn will provide a good faith estimate for care, and payment is expected prior to services being rendered.
What services does Dr. McLawhorn's surgical fee cover?
Aside from performing the actual surgery, Dr. McLawhorn's surgical fee covers pre-surgical planning and routine postoperative care within 90 days of the date of surgery, including office visits with him, phone calls with Dr. McLawhorn and his staff, and other routine administrative tasks. It does not cover hospital services, radiology, other procedures, or care provided by others.
Dr. McLawhorn's professional fee directly supports running his practice. It allows him to invest in the necessary resources, equipment, and staff required to deliver effective orthopedic care. Running the practice involves various administrative and staffing expenses. These include personnel salaries, office rent, utilities, medical supplies, and insurance coverage, among others.
I have a Medicare supplemental insurance plan. Can I be reimbursed through this plan?
No, Medicare supplemental insurance plans will not reimburse you for Dr. McLawhorn's professional fees. However, these supplemental plans will cover services such as the hospital stay, imaging, anesthesia, medicines, and other ancillary services as they would if you had surgery with a Medicare-participating surgeon.
I have a commercial secondary insurance plan. Can I be reimbursed through this plan?
Yes, it is possible that a non-Medicare commercial secondary insurance plan will reimburse you for a portion of Dr. McLawhorn's fee, depending on the underlying contract between that carrier and Dr. McLawhorn.
I have Medicare Part B with a commercial secondary insurance plan. Will Dr. McLawhorn file a claim with the commercial carrier on my behalf?
No, it is the policy not to file the claim for the patient. All necessary documentation and codes can be supplied to the patient upon request to assist with their filing a claim on their own.
I anticipate needing assistance paying for care with Dr. McLawhorn. What resources are available?
Hospital for Special Surgery and Stamford Hospital both offer financial assistance for qualifying patients who need assistance paying for hospital services. The office can connect you with these programs, if you think you might be eligible. However, Dr. McLawhorn's fees are not covered through these programs.
Most patients will have at least a coinsurance, copayment and/or deductible to pay Dr. McLawhorn for his services, including surgery. These balances are the patient's responsibility to pay. It is advised to discuss these fees ahead of time with your insurance provider and receive an estimate for your out-of-pocket expenses for care. Dr. McLawhorn may collect some of these fees prior to surgery. If you think you may need a payment plan to cover your portion of Dr. McLawhorn's fee, we recommend applying for CareCredit®, which is a credit card to pay for health and wellness care. You may scan the QR code to explore financing with CareCredit.
What are some useful terms to know in order to better understand my health insurance and paying for my health care?
- Premium: The amount of money you pay regularly (monthly, quarterly, or annually) to maintain your insurance coverage.
- Deductible: The fixed amount you must pay out of your own pocket before your insurance starts covering the expenses. For example, if you have a $500 deductible, you'll pay the first $500 of a covered claim, and then your insurance will kick in.
- Copayment (Copay): A specific amount you pay for a medical service or prescription drug, usually due at the time of service. For example, your copayment for a doctor's visit might be $20.
- Coinsurance: The percentage of costs you are responsible for paying after you've met your deductible. For instance, if you have 20% coinsurance, you will pay 20% of the covered expenses, while the insurance company covers the remaining 80%.
- Explanation of Benefits (EOB): A document you receive from your insurance company after a claim has been processed. It explains the costs, services, and amounts covered or not covered for a specific medical treatment or procedure.
- Charges: Charges refer to the amounts listed on a medical bill or statement for the services or treatments you received. These charges are the initial prices set by healthcare providers for their services. However, it's important to note that the charges may not reflect the actual amount you will end up paying.
- Payments: Actual payments, on the other hand, represent the real amount of money you or your insurance company will pay for the medical services you received. The actual payments are determined by various factors, including your insurance coverage, negotiated rates between your insurance company and healthcare providers, deductibles, copayments, and coinsurance.
What are some common patient perceptions about insurance reimbursement for total joint replacement?
Dr. McLawhorn surveyed approximately 250 of his patients to explore this topic.
What were the characteristics of the patients surveyed?
Ninety percent (90%) were 65 years of age or older, with 78% having Medicare insurance. Fifty-eight percent (58%) were female. Eighty-four percent (84%) had never had a joint replacement before. Ninety-five percent (95%) had annual household incomes greater than or equal to $50,000, and 82% had undergraduate or higher level degrees.
What did they think is reasonable fee for an orthopedic surgeon to receive for performing hip or knee replacement surgery?
The average answer to this question was $14,000 (see red plot in the figure below, labeled "Reasonable Fee").
If insurance did not cover the entire surgeon fee, what was the most they would be willing to pay out-of-pocket to have the surgery performed?
The average answer to this question was $7,500 (see blue plot in the figure below, labeled "WTP").
How much did patients estimate that Medicare actually pays an orthopedic surgeon for performing a total joint replacement?
The average answer to this question was $11,500 (see black plot in the figure below, labeled "Medicare"). The actual amount Medicare pays the surgeon for joint replacement is approximately $1,250, or 820% less than the amount patients estimated that Medicare reimburses a surgeon.
What were the top factors influencing patients' willingness to pay (WTP) for joint replacement surgery?
When it comes to elective joint replacement surgery, most patients realize that there's no arbitrage for experience. So, they most valued Dr. McLawhorn's experience. Additionally, they valued his expertise with special techniques and implants, the surgical outcomes he achieves, and his reputation.
