Joint replacement surgery is one of the most predictable healthcare events you'll plan — meaning you have time to get the financial side right. Done properly, your out-of-pocket costs can be near zero. Done without preparation, the bill can exceed R100,000. Here's how to prepare.
The Honest Starting Point
Hip and knee replacement are PMB procedures — your scheme must fund them when clinically indicated. But PMB covers the procedure at scheme tariff, which is significantly below what most private orthopaedic surgeons charge. The gap between tariff and surgeon billing is the central financial risk. Gap cover is the solution — but it must be in place, with waiting periods served, before the surgery date.
Step 1: Confirm Clinical Indication — Document It Properly
Your orthopaedic surgeon needs to document the clinical case for joint replacement in a way that supports PMB pre-authorisation:
- X-ray evidence of joint degeneration (Kellgren-Lawrence grade 3–4 for OA; other findings for RA/AVN)
- Record of conservative treatment — at least 3–6 months of documented NSAID therapy, physiotherapy, and/or intra-articular injections
- Functional impairment documentation — pain scores, mobility limitation, impact on daily activities
Without clear documentation of all three elements, schemes sometimes attempt to decline pre-authorisation as "not clinically motivated." Your surgeon should anticipate this and document proactively.
Step 2: Pre-Authorise Early — At Least 3–4 Weeks Before Surgery Date
Do not book a surgery date before receiving written pre-authorisation.
Pre-authorisation process: 1. Your orthopaedic surgeon's rooms submit the pre-authorisation request to your scheme, including clinical notes, X-rays, and surgical plan. 2. Your scheme's managed care company (orthopaedic case manager) reviews and approves or requests additional information. 3. On approval, you receive an authorisation number — keep this number.
If your scheme's orthopaedic case manager requests an additional clinical opinion or imaging, cooperate promptly — delays extend the timeline.
Important: Pre-authorisation is not a price guarantee. It authorises the procedure; it does not cap what the surgeon will bill.
Step 3: Choose Surgeon and Hospital Carefully
Hospital: Confirm the hospital is on your scheme's DSP panel. A DSP hospital means the facility fee is largely at tariff — most of the cost is covered. Using a non-DSP hospital voluntarily incurs a facility co-payment.
Surgeon: Most private orthopaedic surgeons in SA bill above scheme tariff. The question is how far above. Ask: - "What rate do you charge for total hip/knee replacement (surgeon fee)?" - "What is the medical aid scheme tariff, and what will the shortfall be?"
Get the shortfall amount in writing. Confirm your gap cover covers this shortfall amount within your policy's OPL.
If the shortfall exceeds your gap cover OPL, you have three options: accept the OOP cost, negotiate a lower rate with the surgeon, or choose a different surgeon who bills closer to tariff.
Step 4: Sort Out the Implant Decision
Your surgeon will discuss implant options. Before agreeing to any component upgrade:
- Ask: "Which components does my medical aid fund under the PMB, and which are upgrades I pay for?"
- Get the implant cost breakdown in writing before the surgery date.
- Decide whether the clinical benefit of a premium implant (longer-wearing ceramics, patient-specific jig) justifies the OOP cost to you personally.
For most patients, standard scheme-funded implants are entirely appropriate and have excellent long-term outcomes. Premium implants may be worth considering for younger patients (under 60) who want to minimise revision surgery risk over a longer remaining lifetime.
Step 5: Notify Gap Cover Before Admission
Contact your gap cover provider: - Confirm the procedure is covered under your policy - Pre-notify the admission (many policies require this for elective procedures) - Get a pre-notification reference number - Confirm the surgeon and anaesthesiologist are covered under your OPL
Most gap cover policies have a simple online pre-notification process. Do this 1–2 weeks before the surgery date.
Step 6: Understand Post-Operative Physiotherapy
Joint replacement rehabilitation requires 6–12 weeks of physiotherapy post-operatively. In-hospital physio (2–3 days) is part of the PMB hospital admission. Post-discharge outpatient physio is from your day-to-day physiotherapy benefit.
Ask your scheme: "How many physiotherapy sessions do I have for the year?"
If you've used therapy sessions earlier in the year, your post-op physio benefit may be limited. Plan ahead — if possible, avoid elective therapy sessions (sports physio, chronic back pain physio) in the months before a planned joint replacement to preserve your annual physiotherapy allowance for post-operative rehabilitation.
Waiting Period Check — For Switchers or Recent Joiners
If you have joined a new scheme in the past 12 months and have known joint disease, your scheme may impose a waiting period for this pre-existing condition. Joint replacement during a waiting period will not be funded.
Check your scheme joining documentation for the waiting period terms. If a waiting period applies, your surgery should be deferred until it expires — or remain with your current scheme which has no waiting period for the established condition.
Support Resources
South African Orthopaedic Association (SAOA): saoa.org.za — find a specialist Council for Medical Schemes: 0861 123 267 | www.medicalschemes.co.za
Talk to Eldon
Joint replacement is one of the most plannable medical events. AURA helps members confirm PMB eligibility, identify DSP surgeons and hospitals, check gap cover OPL against expected shortfalls, and avoid surprise bills.
Plan for joint replacement — check your cover →