Costs in healthcare can be confusing. If you are unsure about your insurance situation, please talk to Dr Constantin's team; they are well versed in navigating these issues.
This page explains how your cover affects where your surgery happens, who sends you a bill, and what a "gap" is. Before any operation you will receive a written estimate of fees, so you can check your cover and make an informed financial decision.
Your cover, your options
Your type of cover decides where your surgery is performed and who pays for it. Find your situation below.
| Your cover | Where Dr Constantin operates | Who pays | What you need |
|---|---|---|---|
| Private health insurance | Mater Hospital | Medicare and your health fund pay rebates; any remaining gap is paid by you | Hospital cover that includes your procedure, with waiting periods served |
| Medicare only (public patient) | Canterbury Hospital, via the public waiting list | Medicare and the public hospital system; there are no surgeon or hospital fees | A Medicare card and a GP referral |
| Self-funded (no private cover) | Mater Hospital | You pay all fees; Medicare still rebates part of the doctors' fees | A written estimate and payment arrangements before surgery |
| Workers compensation | Mater Hospital | Your workers compensation insurer, directly | An accepted claim, your claim number and insurer approval for surgery |
| CTP (motor vehicle accident) | Mater Hospital | The CTP insurer, directly | An accepted claim, your claim number and insurer approval for treatment |
| DVA (Veteran Card holders) | Mater Hospital or Canterbury Hospital | Department of Veterans' Affairs, directly | Your Veteran Gold or White Card |
Private patients
As a private patient, you choose your surgeon. Dr Constantin performs your operation at the Mater Hospital, North Sydney, and personally oversees your care in hospital and your follow-up in his rooms. Surgery can usually be scheduled at a time that suits you.
Medicare-only (public) patients
If you do not have private health insurance and you need surgery, Dr Constantin can place you on his waiting list at Canterbury Hospital. There are no surgeon or hospital fees for surgery in the public hospital. Waiting times depend on how urgent your condition is, and the hospital schedules your surgery. Follow-up will be with Dr Constantin in his rooms.
Workers compensation patients
In NSW, surgery under workers compensation must be approved by the insurer beforehand, except within 48 hours of the injury. Dr Constantin's rooms send the request for you, and the insurer must decide within 21 days. Fees are set by the NSW regulator (SIRA) and billed straight to your insurer, so you should not be out of pocket. Please bring your claim number and your insurer's contact details to your first appointment.
CTP (motor vehicle accident) patients
If you were injured in a motor vehicle accident in NSW and have an accepted CTP claim, the CTP insurer pays for reasonable and necessary treatment. Bring your claim number to your appointment. We will seek the insurer's approval before surgery and bill the insurer directly. If your claim is not yet accepted, or approval is declined, we will discuss your options, including using your private health insurance.
Self-funded patients
If you would prefer not to wait, you can pay for your surgery yourself at the Mater Hospital. Medicare still pays 75% of the Medicare schedule fee for the doctors' services, but you pay everything else, including the full hospital, theatre and implant costs. We will give you a full written estimate so you can decide.
Not sure which applies?
Dr Constantin's team can talk you through all the options and discuss what best applies to you. Call the rooms on 02 9409 0503.
Checking your private health cover
Not every hospital policy covers every shoulder operation. The most common surprise is shoulder replacement. Check your policy before surgery is booked.
Which tier covers your operation?
Since 2020, every hospital policy in Australia is classed as Basic, Bronze, Silver or Gold, and each tier must include set "clinical categories". The three that matter for shoulder and elbow surgery are:
| Clinical category | Typical shoulder and elbow operations | Basic | Bronze | Silver | Gold |
|---|---|---|---|---|---|
| Joint reconstructions | Rotator cuff repair, shoulder stabilisation, biceps tenodesis, distal biceps repair, AC joint reconstruction | Optional | Yes | Yes | Yes |
| Bone, joint and muscle | Arthroscopy, decompression, frozen shoulder release, fracture fixation | Optional | Yes | Yes | Yes |
| Joint replacements | Anatomic, reverse and partial shoulder replacement; revision; elbow replacement | Optional | Optional | Optional | Yes |
"Optional" means your fund may include it, but does not have to. Policies labelled Bronze Plus or Silver Plus sometimes add joint replacements, so check your own policy. Some policies cover a category on a "restricted" basis, which pays only for treatment as a private patient in a public hospital and can leave large out-of-pocket hospital costs.
Waiting periods
If you have just joined a fund or upgraded your cover, waiting periods apply:
- 12 months for a pre-existing condition
- 2 months for all other hospital treatment
A condition is "pre-existing" if you had signs or symptoms of it in the six months before you joined or upgraded, even if it was never diagnosed. Your fund's medical adviser makes that decision, not you or your surgeon. If you need surgery while serving a waiting period, the public system remains available to you.
Excess and co-payments
Most policies have an excess, a set amount you pay towards your hospital stay. It is paid to the hospital, not to Dr Constantin, and is separate from any doctors' gap.
Questions to ask your health fund
Once Dr Constantin recommends surgery, our rooms will give you the MBS item numbers for your operation. Call your fund with them and ask:
- Am I covered for these item numbers, and have I served all waiting periods?
- What excess or co-payment will I pay to the hospital?
Fees and payment
You will always know the cost before you commit. Consultation fees are quoted when you book, and surgical fees are given to you in writing before surgery is scheduled.
Consultations
For consultations in the rooms, Medicare pays 85% of the schedule fee and you pay the difference. Private health insurance cannot help here: by law, funds cannot cover specialist appointments outside hospital.
To claim a Medicare rebate, you need a current referral from your GP or another specialist. For consultations, our team will organise your Medicare rebate for you, so it is paid straight back into your bank account. This applies to consultations only. For surgery, Medicare and your health fund are claimed as set out in your written estimate below.
Surgery: your written estimate
If Dr Constantin recommends surgery, you will receive a written estimate ("informed financial consent") before your operation is booked. It lists:
- the MBS item numbers for your procedure, to check with your health fund
- Dr Constantin's surgical fee
- the surgical assistant's fee
- the expected Medicare and health fund rebates
- your estimated out-of-pocket amount ("the gap")
The anaesthetist and the hospital will invoice you separately. Our rooms will give you their contact details so you can get their estimates too. The final fee can differ from the estimate if the operation turns out to be more complex than planned; we will explain any change.
What is a gap?
The gap is the part of a doctor's fee that Medicare and your health fund do not pay. It exists because the government's Medicare schedule fee for an operation is often well below what it actually costs to provide the service.
How rebates work in hospital
For each operation, the government sets a Medicare Benefits Schedule (MBS) fee. When you are a private patient in hospital, Medicare pays 75% of that fee and your health fund pays the remaining 25%. The doctor's fee is usually higher than the MBS fee, and the difference is called the gap.
Who sends you a bill
Surgery involves several separate providers, and each one may have its own gap:
- Your surgeon: Dr Constantin's fee for the operation and in-hospital care.
- Your surgical assistant: a second doctor who assists in theatre; this fee is included in your written estimate.
- Your anaesthetist: billed separately by the anaesthetist's own practice.
- The hospital: accommodation, theatre and implant costs, most of which are covered by your fund, less your excess.
You may also receive smaller bills for pathology, X-rays or scans done while you are in hospital.
Appointments and enquiries
Missed appointments
We understand that life can get in the way. Pain, work, family and the stress of an injury can all make it hard to keep an appointment, and we will never judge you for that. If you can, please let us know as early as possible so we can offer your time to another patient who is waiting.
If an appointment is missed without notice, we are very happy to rearrange it. When we do, the consultation fee will be payable in advance at the time of booking. We will still organise your Medicare rebate for you after your appointment.
Questions about fees?
Our staff are happy to talk through your costs at any stage: before your consultation, before surgery or afterwards. Call the rooms on 02 9409 0503.
Frequently asked questions
Will my health fund pay for my consultation?
No. By law, health funds cannot pay for consultations in the rooms, but Medicare pays a rebate towards your consultation fee.
Do I need a referral?
Yes, to claim a Medicare rebate. A GP referral is usually valid for 12 months, and one from another specialist for 3 months. Workers compensation and CTP patients also need a referral, plus their claim number.
I have private health insurance. Can I use it at Canterbury Hospital?
Yes. You can choose to use your cover as a private patient in a public hospital, often called "private in the public". As a thank you for using your cover, there is no excess to pay: the hospital bills your health fund directly, which helps offset the Medicare costs of your care in hospital. There is no gap for your surgery, although you will still be placed on the hospital waiting list.
My fund says I'm covered. Why is there still a gap?
When your fund says you are "covered", it is mostly talking about the hospital. The hospital bill reflects the operation you are having, the cost of any implant and the length of your stay, and it can run to tens of thousands of dollars. Your fund pays this directly, so you never see it. The doctors' fees are a separate matter: for your surgeon, anaesthetist and assistant, the fund pays only its share of the Medicare schedule fee, which covers just a portion of their charges. The difference is the gap.
Will the anaesthetist's fee be on my estimate?
No. The anaesthetist bills separately. We will give you their details so you can ask for their estimate before surgery.
Is a shoulder replacement "covered"?
Not always. Joint replacement is a separate category on hospital policies, and many policies leave it out. Before surgery is booked, check with your fund that your policy includes shoulder replacement, using the item numbers we give you.
I injured my shoulder at work but my claim hasn't been accepted yet. Can I still see Dr Constantin?
Yes. You can attend as a private patient while the claim is assessed. Let us know, and we will discuss how fees will be handled.
Ready to book?
A referral from your GP or specialist is needed to claim a Medicare rebate.