Direct Pay and Out-of-Network Care

At Sohn Orthopaedics, we believe in delivering high-quality, personalized shoulder and arm care - whether or not we're contracted with your insurance company*. For patients with high-deductible plans, out-of-network (OON) benefits, or no insurance at all, we offer transparent pricing and help you seek reimbursement from your insurance whenever possible.

We perform surgery at Hoag Orthopedic Institute (Aliso Viejo), Laguna Niguel Surgery Center, Mission Hospital, and Saddleback Hospital - facilities that are in-network with most insurance plans. This means your hospital or surgery center bill is usually processed at your highest benefit level, even if Dr. Sohn's professional fees are billed out-of-network.

Our professional (surgeon) fees are billed separately from the facility and anesthesia charges. We work hard to help you maximize your insurance benefits whenever possible. Before surgery, our team will verify your benefits, obtain prior authorization if required, and explain the full billed amount for the surgeon's fee.

Payment for the surgeon's fee is collected in full before surgery. After your insurance processes the claim, we will promptly refund any overpayment within 30 days. If your insurance sends payment directly to you, you keep it - you have already satisfied your financial responsibility with our office.

If your insurance plan does not offer OON benefits, or if you prefer not to use insurance, we offer transparent pricing for most procedures.

Clinic Visit Fees

(These rates include your exam and discussion. Imaging may be included at our discretion.)

• New Patient Consultation with Roger Sohn, MD: $310
• New Patient Consultation with Theresa Ho, PAC: $279
• Follow-Up Visit (MD or PAC): $253

We collect payment in full at or before your visit. If your insurance allows, we will submit a claim on your behalf. Any reimbursement from your insurance will be sent directly to you or, if sent to our office, we’ll deposit it and issue you a prompt refund.

If your plan does not allow us to bill - or if you prefer to submit your own claims - we'll provide superbills and itemized receipts to support your insurance or HSA/FSA reimbursement.

Surgical Fees

(Surgeon's professional fee only - does NOT include charges from the surgery center, anesthesia group, or implant suppliers.)

Our direct-pay fees cover only the surgeon’s fee. Common bundled estimates:

• Rotator Cuff Repair: $4,949 - includes biceps tenodesis & related debridement
• Shoulder Replacement: $6,282 - includes biceps tenodesis & joint capsule release
• Revision Shoulder Replacement: $8,423 - includes removal of old hardware
• Shoulder Instability Repair (non-Latarjet): $5,747 - includes remplissage if needed
• Latarjet or DAS Procedure: $6,711 - includes remplissage if needed
• Elbow Ligament Reconstruction (Tommy John): $2,948

These are examples only. Please ask for details before your surgery.

What Might Still Be Covered In-Network

Even if we are OON for the surgeon’s fee, many aspects of your surgical care may still be billed in-network by other providers, including:

• Hospital or surgery center facility feesAnesthesia servicesMost implants and surgical supplies
• Anesthesia servicesMost implants and surgical supplies
• Most implants and surgical supplies
• Intraoperative imaging

We use in-network facilities whenever possible to help lower your overall costs.

How the Process Works for Surgery

For patients with PPO insurance that includes OON benefits:

1. Verify Benefits & Authorization - We confirm your OON benefits and obtain prior authorization when required.
2. Collect the Surgeon's Fee in Full - You pay the full billed amount for the surgeon's fee before your procedure date.
3. Submit the Claim - We submit the surgeon's claim to your insurance (when permitted).
4. Reconcile After Processing -
5. If the insurer sends payment to us, we apply it to your account and refund any overpayment within 30 days.
6. If the insurer sends payment directly to you, that payment is yours to keep - you have already satisfied your responsibility with us.

If We Cannot Bill for You - We provide a superbill (with CPT and diagnosis codes) and an itemized receipt for insurance or HSA/FSA reimbursement.

Important Notes

• A prior authorization is not a guarantee of payment.
• Reimbursement varies by plan; some services may be partially covered, others denied.
• Our assistance with billing does not make us financially responsible for what your insurance chooses to pay.

Flexible Payment Options

We accept:

• Major credit/debit cards
• HSA/FSA cards
• Personal checks
• CareCredit - a medical financing option with low or no interest plans, usable for both clinic visits and surgical fees.

Legal & Billing Transparency

We comply with the No Surprises Act by providing:

• Good-faith estimates before your visit or surgery
• Clear, upfront pricing
• Prompt receipts and billing documentation

Medi-Cal/CalOptima Patients*

We do not participate in Medi-Cal/CalOptima and cannot treat patients who have Medi-Cal or CalOptima. Under current regulations, we cannot accept cash from patients enrolled in Medi-Cal/CalOptima, even if they wish to pay out-of-pocket. The only exception is for patients enrolled in reassigned Medi-Cal/CalOptima HMO plans, where we are contracted and reimbursed directly by the HMO.

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Patient FAQ – Direct Pay & Out-of-Network Care