About Surgery

We are located at Suite 2.06, Level 2, Pindara Specialist Suites, 29 Carrara Street Benowa. Pindara Specialist Suites are located within the premises of Pindara Private Hospital, Benowa. The entrance to the suite is via Carrara Street behind Benowa Gardens shopping centre into Pindara multistorey free car park. Take the lift to Level 2 (green décor when you exit lift) and turn right into the Specialist Suites. There is also a drop off facility (5 minutes car park) in front of Hudson’s café at the ground level.

Ans. Our practice hours are from 9 am to 5 pm Mon-Fri

– Dr Nihal consults on Monday am , Tuesday ,   Wednesday am &  Friday am

– Dr Nihal operates at Pindara every Monday, Wednesday and Friday afternoons.

– Thursday is Dr Nihal’s day off – the Day of Rest!

It would be useful and helpful if you could bring the following to your first appointment

• Referral letter from your GP or specialist or Emergency doctor is MUST
• All old X-rays/MRI/CT/Ultrasound films & scans with their reports (Not just the reports)
• Please make sure you have printed hard copies of your X ray/MRI/CT (not only the CD copies). If you only have CD’s then please ask the imaging company to print hard copies for you to bring to this clinic. If we are unable to see the images then you may be asked to have a repeat X-ray at Pindara Hospital before the consultation, which will cost you time and money.
• All your Medicare/Health fund/ DVA Cards
• Any correspondence/letters from previous doctors/specialists
• List of your medical conditions/medications and details of any previous surgery
• List of questions which you wish to ask during consultation
• This practice is a private practice and is not a Bulk Billing or No Gap practice. Therefore consultation fee must be paid on the day of consultation. Please bring your EFTPOS/Visa/Master cards or cash. We do not accept American Express or cheques.

For WORK COVER /Third party patients: Please make sure you have the valid active claim number of your work-related injury as well as the name, address, contact number of your employer and case manager. It is your responsibility to get approval for consultation. We may be able to assist you regarding this. If you do not have the approval then you are liable to pay the consultation fee on the day of consultation and then claim back from work cover at a later date. PS. Please remember to download from our website and complete the “New Patient Registration Form” and bring to our practice on the day of your consultation.

Ans: Yes, however we require written approval from either work cover or third party insurance claim before you can be seen. It is your responsibility to obtain an approval. We would be happy to provide assistance regarding this.

You will be asked to complete the new patients registration form and/or work cover injury forms if you have not already downloaded and completed the new patient registration form. If your condition needs application of plaster, splint, moon boot or injection etc then there will be an extra cost for these services which will be fully discussed beforehand and paid for on the same day. If you have private insurance with extras cover then some health funds partly rebate the cost of splint/boot. Please check with your health funds and we will provide you with a receipt and supporting letter.

 

• Bunion, hammer toe & foot deformity correction
• Arthritis of ankle & foot joints
• Ankle pain, sprain & instability
• Achilles tendon & heel pain
• Diabetes related foot disorders
• Special interest in sports & Dance (including ballet) related foot & ankle injuries
• In-growing toenail surgery
• Flat foot, foot drop and cavus foot reconstructive surgery
• Morton’s neuroma, Metatarsalgia
• General common orthopaedic trauma & fracture management
• Revision and Re do foot & ankle Surgery
• Paediatric & adult acute trauma/soft tissue / fracture management

Yes- Please ask our staff to put your name on our cancellation list and we will contact you to come early should an appointment become available due to a last minute cancellation.

• 5-6 years in Medical school to obtain MB BS, MBChB, or MD, comprising the basic medical degree
• 2-3 years or even longer basic internship, junior doctors training under supervision in various medical and surgical specialities within hospitals
• 5- 6 years of advanced training in orthopaedic surgery under supervision and attainment of a higher surgical degree for example FRCS, FRACS etc
• 1-2 years of sub-speciality training ( fellowship) under the supervision of an eminent orthopaedic surgeon either in the home country or overseas.
• After 15-16 years of medical and surgical training, only then can a surgeon work independently as a “Consultant Orthopaedic Surgeon”, “Orthopaedic Specialist” , “ Orthopaedic Foot & Ankle Surgeon”.

Dr Nihal is a fully trained Trauma and Orthopaedic Surgeon and takes all other general orthopaedic trauma and fractures including children’s fractures.

At present Medicare does not recognise Podiatric Surgeons as “ medical specialists” thus their fees do not attract any rebate. The majority of health funds also do not recognise Podiatric Surgeons as “Medical Specialists” thus your health fund may or may not pay the hospital and theatre costs if you chose to have surgery by non MBBS / non FRCS/non FRACS podiatric surgeon.

Please ask your treating podiatric surgeon and the hospital administration where you are having foot surgery as regards the costs and rebates. You must also ask the treating podiatric surgeon whether s/he has prescribing rights to prescribe antibiotics should you develop minor post-op infections or whether s/he has any admitting rights in a major private hospital should you develop a serious post op-infection requiring I/V antibiotics and/or wound washout and debridement under GA etc.

Ans: E-mail correspondence is not a secure and confidential way to communicate discussions or confidential clinical information. Hence this practice does not partake in email consultations.

Practice e-mail communication is only reserved for making, changing or cancelling appointments, making requests to issue sickness certificates, contacting us for non-urgent post-op queries and any other non-urgent matters, particularly if you are abroad.
If you have a lot of clinical questions relating to your surgery then please make an appointment to discuss this in person.

Ans. Yes. Please let my staff know that you have sustained an acute fracture or tendon rupture we have urgent slots on Monday and Tuesday and would be more than happy to slot you in.

Ans. Dr Nihal only work in private hospitals and has no practice privileges in the public hospitals. Therefore private health insurance is essential for any surgery carried out in a private hospital.However we do see un-insured uninsured patients who wish to seek a second opinion or where their GP has specifically requested an expert opinion from Dr Nihal.

(a)  Dr Nihal provides a holistic treatment & service from start to finish. Even if you pay Dr Nihal’s  surgical fees, the hospital & anaesthetic fees, unexpected complications such as infection do occur, particularly in the case of foot & ankle surgery, which is known to carry higher risks of post-op complications than for example knee & hip surgery. Should this happen, you will need readmission and further treatment in private hospital, the cost of which may run into thousands of dollars on a daily basis. Thus if you are self-funded, these unexpected costs may become unaffordable.

(b) You may have question that you had “knee arthroscopy surgery: by Surgeon  X and when you had post op infection the surgeon X  treated you in public hospital at no added cost. This may be true where surgeon X works both in a private and a public hospital or treated you as a public or intermediate patient in the public hospital. However, Dr Nihal only works in the private sector and is therefore unable to admit you in a public hospital for any unexpected or expected complications and treat you personally.

For the above reasons, Dr Nihal prefers not to operate on uninsured/self funded patients in the private hospital, only to send them off to the public system for another surgeon to deal with complications, either expected or unexpected. It is unlikely that this group of patients would be able to afford the $900 a day (or more) hospital admission fee and costs relating to any theatre/revision surgery/ICU etc.

Apart from the many benefits offered by private health insurance, it should be taken into account that all hospital care, theatre and instrumentation costs are also covered by health funds which usually run into many thousands of dollars.

(c ) Self-funded patients need to be aware of  the other costs in addition to the Dr Nihal’s fees, for example  surgeon’s assistant fee , anaesthetist fee , hospital ward, theatre costs , medication , fees for x-rays taken during & after surgery. Other hidden and unpredictable costs might include plates, screws or synthetic bone grafts or any other materials used during surgery. Again the cost of these items may be prohibitive.

(d) The foot & ankle is a complex structure and surgery, by definition, is also complex and It often results in prolonged periods of post-op care, requiring a longer stay in hospital, extended periods of rehabilitation & physiotherapy in a private rehab unit. This will also incur extra expenses for the uninsured/self funded patient.

(e) In addition to the expected complications relating to foot & ankle surgery, there may be unexpected cardiac, anaesthetic or other complications requiring a period of in-patient stay either in the ward or even  ICU  or CCU. This would significantly inflate a patient’s medical expenses. However these situations would be covered by health insurance. Here is a case scenario of a patient undergoing routine knee arthroscopy. Post-operatively he developed a heart attack requiring admission to ICU, subsequent intervention & treatment. He received a hospital bill for $30,000 for a presumed routine procedure where he paid his orthopaedic surgeon only $1,200 for the knee arthroscopy. Now he is faced with a $30,000 bill to pay due to an unexpected complication.

(f) If  you are an uninsured/self funded patient, then please ask your GP to refer you to any other Orthopaedic foot & ankle surgeon who has practice privileges in both the private and public hospitals, so that should a complication develop post-operatively, you can be transferred to the public hospital for on-going care at no extra cost to you.

(g) Should you wish to see Dr Nihal and have surgery by him, then it is up to you to join a health fund of your choice and serve the waiting period before coming to our clinic for treatment.

Ans: The decision to have elective foot/ankle surgery should not be made in a rush. Dr Nihal will always explain the non-surgical and surgical options available for your foot/ankle disorder. Please make a decision only when you have understood all the risks, benefits and limitations of each treatment. Please also keep in mind that the surgeon cannot give a 100% guarantee of perfect results since expected and un-expected surgical complications may arise through no fault of anyone. The vast majority of patients do not develop these surgical complications, but should you fall into that small percentage of those that do develop complications, then there is always the risk that you may be worse off after surgery. The more complex the condition you have, then the more complex will be the surgery. Complex operations may result in complex and serious complications.

The post-operative period after foot & ankle surgery is very cumbersome and can be very frustrating. This is due to the application of Plaster/Boot/Splint etc and a period of non-weight bearing on the operated leg. This period may last for 6-12 weeks, but in some complex cases, up to 20-24 weeks. Please make sure that you understand this period and arrange for someone to help with your daily chores etc.

Ans: There are risks associated with any kind of surgery and foot and ankle surgery is no different. The mainstay of surgery involves either re-alignment or fusion of bones. Occasionally, however deformity can be over and under-corrected or bones fail to unite. Deformity can also recur despite an initial good correction. These complications may require further surgery or even amputation. Fusion of bones in the foot and ankle can also increase the risk of arthritis developing in adjacent joints in the long term.

Other possible well-documented complications include: infection, wound problems, neuroma, numbness, under and over corrections, residual pain and swelling, nerve, vessels, tendon damage, fracture of bone or implant, compartment syndrome, stiffness, non-union, malunion, recurrence of initial problem, re-operation, scar tenderness, metalwork problems and removal, blood clots in legs/lungs, Sudeks’s atrophy, post-op temporary\permanent use of insoles, splint or modified footwear, circularity problems in toes/foot which may require amputation. Apart from anaesthetic and medical complications, there is a small risk of being worse off after surgery. There is also the possible risk of long-term diminished function in walking, dance, sports or daily activities.

Smoking must be ceased at least 6 weeks before the surgery and until full healing of your condition (approx 3 months) – brackets need to be on one line. Smoking significantly increases foot and ankle surgical complications for example interference of bone & wound healing, infection & non-union to name a few. There are also issues with anaesthetic complications and increased risks of blood clots to the legs & lungs. It is in the best interest of the patient, surgeon & anaesthetist that the patient ceases smoking completely – both active and passive smoking.

In some cases, you may need physiotherapy but in the majority of cases when foot bones are fused, you do not need formal physiotherapy. Dr Nihal will advise you accordingly after the operation.

Ans: If you had surgery on your left foot/ankle then you can drive an automatic car, two weeks post surgery once the surgical wound has healed. You cannot drive a manual car until the fracture/osteotomy/fusion has completely healed and once you are allowed to fully weight bear. This may vary from 6-12 weeks.

If your right foot/ankle has been operated on then you cannot drive until your operated condition has fully healed and you are able to fully weight bear. Again this may vary from 6-12 weeks. If you have a right Achilles tendon rupture then you may not be able to drive for approximately 3-4 months post injury/post surgical repair.

Ans: if you have any chronic condition of the foot/ankle then we need a weight-bearing/standing X-ray of both the foot and ankle. It is important to have the X- ray of the foot as well as the ankle as many X-rays miss one or other part! We need to see both.

However if you have a fracture or suspected fracture or you are unable or are unsafe to weight-bear, then non-weight-bearing X-rays of both the foot & ankle would suffice.

Minor foot/ankle operations are performed as a day case. For the majority of operations, the hospital stay is around 1-2 days. However, complex operations may require 5-7 days stay in hospital. If you have or develop an infection, then the hospital stay is unpredictable, as it will depend on how quickly we can eradicate the infection with surgical debridement, IV antibiotics and regular dressings etc. This will obviously vary widely between individual patients.

This depends on the type of surgery you had. Generally the recovery time is longer in foot/ankle surgery as compared to surgery to other parts of the body such as carpal tunnel release, hip and knee replacement surgery. Foot/ankle surgeries usually require a period of non-weight bearing and application of a plaster splint, Moon boot and frequent wound care etc. The usual recovery time for minor operations is approximately 3-6 weeks, fractures around 6-12 weeks, and major operations about 6-9 months.

Post-op swelling on the foot/ankle/toe is normal & may last for approximately 3-6 months and in some cases take 18 months to fully resolve. This is due to the foot being a gravity-dependent extremity with a natural tendency to swell. Also the venous and lymphatic drainage may be impaired due to the initial injury, ensuing surgery, immobilisation, varicose veins, gravity, advancing age etc.

Yes- as follows

PRE-OPERATIVE ADVICE

Now that you have signed the consent form and booked your surgery, please note the following information: –

 

1. If you are over 60 years of age, or under 60 with medical conditions, then you will be asked to attend Pindara Hospital Pre Admission Clinic for a Preoperative Assessment before your elective surgery date.  This will include doctor examination, various tests; to make sure you are fit to have a general /spinal anaesthetic. Pindara Pre Admission Clinic phone number is on the front page of the Pindara Patient Admission Guide. Please read carefully the Front page of Pindara Patient Admission Guide and follow all the instructions written on it. Any questions regarding Pindara Admission Guide booklet please contact the numbers written on the front page.
2. Dr Nihal only operates at Pindara Private Hospital. His operating days are Monday PM, Wednesday PM and Friday PM.
3. As you have already been given a date for surgery, my secretary will ring you 5-7 days prior to the surgery date to discuss with you the approximate time of admission, fasting time and the payment (Dr Nihal’s and his Assistant fee). My secretary will also give you a provisional financial breakdown of Surgeon and Assistant’s fees (gap, known gap, or full private fee), which is payable one week in advance of your proposed surgery date. Information regarding this is written on the Gold Coast Foot & Ankle Specialist Clinic, Clinical & Financial Consent Form, which you have signed during pre op consultation with Dr Nihal. If you are not sure about this or have any questions, please do ask before the surgery date either on the phone or in person for 2^nd consultation with Dr Nihal.  It is very important to understand the clinical and financial consent, which is essential for a good doctor-patient relationship and mutual trust.
4. Regarding the name of anaesthetists and their fees, my secretary will also inform you of which anaesthetist group is booked on your surgery day.  Dr Nihal uses two different Anaesthetic groups (a) Coast Anaesthesia Tel number 07 5598 0663) and APS Anaesthesia Tel 07 5574 0018. You may receive a call from one or other of these groups to pay the anaesthetist fee, either a deposit, gap or full fee in advance.  Dr Nihal has no control over anaesthetist’s fees.  Any questions regarding their fees, please call the anaesthetist group directly.
5. You must bring (a) Pindara Consent form (b) Pindara Admission booklet (c) all investigations, in particular hard copies of X-Rays, CT scans, MRI’s etc.  If you do not bring any of the above, especially the Pindara Consent form and X-Rays, then this may result in delay, postponement or even cancellation of your surgery.
6. Following surgery,  my office will ring you for a post-op appointment, usually 8 to 14 days following surgery.

Some facts about Foot & Ankle Surgery

Foot & ankle surgery carries a slightly higher risk of wound complications, as compared to shoulder, elbow, face surgery etc. The foot and ankle is a dependent part of the body, and during walking/standing, gravity tends to result in more oedema/swelling and wound break down. Circulatory problems are more common in the foot and ankle than in the shoulder or elbow, especially in smokers, thus resulting in would healing/ulcer problems.

Post operative period after foot & ankle surgery is very cumbersome and can be very frustrating. This is due to the application of Plaster/Boot/Splint etc and a period of non-weight bearing on the operated leg. This period may last for 6-12 weeks, but in some complex cases, up to 20-24 weeks. Please make sure that you understand this period and arrange for someone to help with your daily chores etc.

If your right foot/ankle is operated on, then you may not be able to drive an automatic car for a period of non-weight bearing as above.

SMOKING MUST BE CEASED before undergoing surgery, and for 8-12 weeks after the surgery. Smokers have a higher risk of complications, including wound-healing problems.

If you have any history of DVT (clot in the legs), Pulmonary embolism (PE), or if you are a young female taking the oral contraceptive pill, then please inform us, or the pre admission clinic. Foot and ankle surgery carries a risk of residual postoperative swelling on the ankle/foot/toes, which may take 6-18 months to disappear.

Last but not least, no surgeon will give you a 100% guarantee of a perfect result after foot/ankle surgery, as expected and unexpected complications can occur. However, even if you do not suffer from any complications, statistics shows us that 5-10% of patients are unhappy after foot and ankle surgery, in spite of appropriate surgery performed.

If you have any questions, please discuss before booking surgery on Ph: 07 5564 6877.

Copyright: The Gold Coast Foot & Ankle Specialist Clinic Benowa – Jan 2015

Yes- as follows

10 Rules: For 10-14 days Post Op.  Instructions for Patients Following Foot & Ankle Surgery – Plaster/Splint/Moonboot/Foot booty/Dressing 

1. Please keep dressings/plaster clean and dry avoiding any water, Ice, dust, dirt, sand, heat etc.

2. Please stay indoors during the immediate post-operative period, and avoid any long car travel until your first post-operative appointment with Dr Nihal. During this period you must maximally elevate the operated leg. Please do not sit in the sun or outdoors in the heat – this may cause sweating, wound moistness & INFECTION.

3. When you have a shower then please make sure you have help available at home to look after your operated leg which must be covered with a WATERPROOF BAG (i.e: no holes) and completely sealed with paper tape to non-hairy skin. If you cannot achieve this then please have a sponge bath or no bath at all initially. UNDER NO CIRCUMSTANCES MUST YOUR POST-OP DRESSING OR PLASTER GET SOAKED IN BATH/SHOWER/RAIN WATER. A moist wound results in maceration of the skin followed often by a horrendous wound infection including Golden Staph infection.

IF YOU GET YOUR DRESSING/PLASTER SOAKED THEN THIS WILL CAUSE INCONVENIENCE TO YOU AND MYSELF AS WELL AS COSTING YOU MONEY TO REPLACE YOUR PLASTER/DRESSING. 

4. Please continue with DVT prevention exercises as described in the white leaflet.

5. The foot/ankle is the most dependent part of the body, and with added gravity, the foot tends to swell after an operation with risk of wound breakdown/dehiscence and disastrous consequences.  Please therefore stay in the house and carry out your usual but limited daily indoor living activities, with maximal elevation of operated leg for the first 10-14 days. 

6. Use crutches/walker/hopper/knee walker /moon boot/post-op shoe provided to you as per instructions from Dr Nihal.  Post operatively the the ward physiotherapist will have explained to you the weight-bearing status on the operated foot/ankle so please follow those instructions. Continue to wear TED stockings for 6 weeks post-op or as otherwise advised.

7. Do not poke anything down the cast or into the wound. Do not use a hot hair dryer or attempt to interfere with the cast in any way, or apply any ointment/ steroid cream/ice, on and around the postoperative wound. Steroid cream causes thinning of the skin & predisposes the wound to breakdown and infection.

8. Please do not smoke (active or passive) for at least 6-12 weeks post-op as smoking increases the risk of bone non-healing and wound complications.

9. Report IMMEDIATELY – Excessive swelling, numbness, constant pins and needles or loss of sensation, severe cramping of the calf muscle, inability to move your toes, cast digging in, any offensive smell or discharge from the operative wound.

10. If you develop breathing problems, shortness of breath &/or chest pain then this may indicate a blood clot in the lungs which is an emergency.  Dial 000 for the Qld Emergency Service or attend your nearest Emergency Dept.

 

Post op Pain Relief:

1. Take analgesics as directed e.g.: Panadeine Forte, Panadol, Brufen (if no contraindication)

2. Take half a tablet 150 mg Aspirin daily for about 6 weeks if you have a plaster on your leg, or until Dr Nihal advises otherwise to have a blood-thinning injection – Clexane (if there is no contradiction)

 

In an Emergency:

If you have any concerns regarding your post-operative dressing/plaster please contact Dr Nihal’s rooms during normal business hours Mon – Fri first & before calling your GP, as Dr Nihal is responsible for your post-operative care. You can contact Dr Nihal at The Gold Coast Foot & Ankle Clinic Tel: (07) 55 646 877

If assistance is needed out of business hours and over the weekend please contact/attend Pindara Accident & Emergency Tel: (07) 5588 9000 or any other local public or private emergency department.

Copyright: The Gold Coast Foot & Ankle Specialist Clinic Benowa – Jan 2015

Foot & ankle surgery carries a slightly higher risk of wound complications, as compared to shoulder, elbow, face surgery etc.  The foot and ankle is a dependent part of the body, and during walking/standing, gravity tends to result in more oedema/swelling and wound break down.  Circulatory problems are more common in the foot and ankle than in the shoulder or elbow, especially in smokers, thus resulting in wound healing/ulcer problems.

Apart from anaesthetic and medical complications, there is a small risk of being worse off after surgery. A possible risk of diminished function in walking, dance, sports or daily activities.

The outcome of surgery depends on so many factors and one of the important factors is the raw material you have to start. The foot and ankle is a complex structure with so many bones, joints, ligaments, muscles and tendons working together and if we operate on one structure then the other adjacent structure/s are likely to ache/ pain or swell, thus this is a likely outcome of any foot and ankle surgery. As we grow or get older and/or subject our foot/ankle to more stresses by walking, running gym and sporty activities, then the existing pathology progresses over a period of time and the new pathology may appear in operated foot/ankle resulting more pain, swelling down the track.  with your daily chores etc.

Post operative period after foot & ankle surgery is very cumbersome and can be very frustrating.  This is due to the application of Plaster/Boot/Splint etc. and a period of non-weight bearing on the operated leg.  This period may last for 6-12 weeks, but in some complex cases, up to 20-24 weeks. Please make sure that you understand this period and arrange for someone to help

Foot and ankle surgery carries a risk of residual post-operative swelling on the ankle/foot/toes, which may take 6-18 month to disappear. 

Last but not least, no surgeon will give you a 100% guarantee of a perfect result after foot/ankle surgery, as expected and unexpected complications can occur.  However, even if you do not suffer from any complications, statistics shows us that 5-10% of patients are unhappy after foot and ankle surgery, in spite of appropriate surgery performed.

Dr Nihal would try his best to do good operation so that you have a good outcome but unable to give you 100% guarantee of perfect results. If you are unsure about surgery, please try non-surgical treatment.

If you have any questions, please discuss before booking surgery on Ph.: 07 5564 6877.

Ans: Dr Nihal is a member of the Australian Medical Association (AMA) and the majority of his fee structure is based upon the recommendations/guidelines of the AMA and has no relationship whatsoever with the Medicare rebate.

Consultation fees  from 1^st Jan 2013: Initial consultation is $190 (Medicare rebate $72.75) & Review appointment is $90. (Medicare rebate $36.55).

Dr Nihal’s initial and review consultation fees increase annually as per the schedule increase in AMA fees and is independent of the Medicare rebate. Please phone our rooms to confirm the current fee structure, before booking an appointment.

Regarding operation fees:

The foot and ankle is a complex structure consisting of approximately 26 small bones, 39 joints, 19 muscles/tendons and 107 ligaments. Hence any surgery is bound to be tricky, fiddly, intricate and complex.

Medicare pays a relatively large rebate for fixing fractures of large bones i.e. femur (thigh bone) /tibia (lower leg bone) but pays a much smaller rebate for fixing fractures of small bones such as those in the foot. The amount of Medicare rebate for foot and ankle surgery does not therefore reflect the surgical complexity, duration of operating time, technical operative skills required, as well as the number of post-op visits in the ward and repeated and recurrent review appointments in the private rooms. Post-op reviews are of necessity and more frequent following foot/ankle surgery than reviews following large bones/joints surgery such as hip or knee replacements.

Dr Nihal’s surgery fee also includes an assistant fee. We will give you the approximate cost of the total fee i.e. surgeon fee & assistant fee before the surgery.

Ans. Dr Nihal’s and the surgical assistant’s fee for the proposed operation will vary according to the complexity of the procedure. If the procedure is more complex and the rebate from Medicare/Health funds is lower and not proportional to the complexity of the procedure then a higher “gap” amount will be payable by yourself. The majority of Dr Nihal’s fee structures are based upon the standard AMA rate guidelines. Thus foot & ankle operations performed by Dr Nihal will often incur “out of pocket expenses – “gap” payment.

The foot & ankle are complex structures & Dr Nihal’s surgery fees are determined by the followings factors:

• Complexity of the operation
• Duration of operation
• Technical skills involved
• Hospital stay
• Number and length of post-operative follow-ups in the clinic & dressing changes etc
• Rebate from your health funds

Our practice will give you the approximate breakdown of the cost for the proposed operation. It is then your responsibility to ask you health fund as to how much money you will get back. Your health fund and the level of cover you have taken determine this amount.

Operations on smaller bones and joints in the foot and ankle attract smaller rebates, so patients will receive less rebate as compared to patients undergoing hip and knee replacements.

The rebate you will receive from Medicare/Health funds is not determined by Dr Nihal but is pre-determined and set by your health funds/Medicare. This amount does not represent the total surgeon’s fee but is financial assistance to cover part of the surgeon’s fee.

If you feel concerned that this amount is low, then you should raise this issue with Medicare Australia and your health fund as to why the rebate for the surgeon’s fee is lower than the AMA recommendations.

Needless to mention, your health fund & Medicare pay a very substantial amount (mostly in thousands of dollars) to the hospital where the procedure is being carried out. Thus it is very important to understand that your health fund primarily operates to cover the large amount of costs involved in hospitalisation for the proposed surgery. This includes the operating theatre costs, ward admission, nursing care, cost of anaesthetic drugs, surgical implants, plates, screws metal rods, ICU care if needed etc.

Ans: Some health funds are strictly “No Gap” health funds. These “No Gap” health funds” prevent us from charging you a “Gap” & restrict us to accept their lower surgery fee which in no way reflects the complexity of foot and ankle surgery. Thus if you are a member of the “No Gap Health funds” then you will have to pay the full amount of Dr Nihal’s fees in advance. After the surgery we will give you the receipt to lodge a two-way claim with Medicare/health fund for your rebate. The amount you will get back will again depend on your health fund & your policy cover.

However should you be a member of the “Gap health funds” then for Dr Nihal’s surgery fee, you may be asked to pay the permissible “gap” called the “Known Gap” (depending on the complexity of the case and rebate from your health funds) and the rest we will collect from your health funds. We will inform you in advance regarding this.

The “gap payment” is actually the “out of pocket expenses” which you will incur after claiming your rebate from Medicare and your health fund. For example, you had surgery where the surgeon and assistant’s fee was $2500, which you paid in advance. After surgery you lodged a two-way claim to Medicare and our health fund. You received $250 from your health fund and $750 from Medicare thus your out-of-pocket expenses for the surgeon’s fee was $1500. The amount of $1500 is the “gap payment” or “out of pocket expenses”.

About the “ Known gap”: the majority of health funds in Australia are “ Gap Health funds”. These funds allow the surgeon to charge a permissible gap from the patient called a “Known gap”. The remaining balance of surgical fees is collected directly from your health fund after your surgery. If you are a member of the “ Gap Health Funds” then you may be asked to pay the “Known gap” only and the rest we collect from your health funds. However this “Known gap” is not accepted by our practice for the more complex foot and ankle surgery cases but may be permissible for the more straightforward procedures. You will be informed before the scheduled surgery regarding “out of pocket” expenses and the “Known gap” if applicable. We will obtain informed consent from you before the surgery.

Ans: Dr Nihal is also happy to do knee arthroscopy or knee replacement surgery on you at no cost to you at all! As mentioned previously the Medicare/health funds rebate for small bones in the foot is comparatively small and does not reflect the complexity of the case as well as not taking into consideration the multiple post-op review appointments following foot surgery. The rebate from Medicare/health funds for surgery to large bones i.e. knee arthroscopy, total knee and hip replacement is a reasonable amount so most surgeons do not need to charge you a gap at all. This practice is also happy to provide “no gap” for knee arthroscopy, hip and knee replacement etc.

Ans. The Medicare rebate is an arrangement between the government and the patient. The Medicare rebate has not increased substantially for many years as compared to the large & ever-increasing costs of running a private practice, inflation and the associated cost of providing quality care to the patients. Medicare/Health funds do not fully cover the surgeon and anaesthetist’s fees. Needless to mention, the surgeon’s and anaesthetist’s fees are only a minor component of the cost for your surgery as compared to the theatre fees, hospital stay, nursing care in the ward, the cost of prostheses, insertion of plates, screws and provision of ICU care if needed. Thus this cost can run into many thousands of dollars, which is fully paid by your health fund/ Medicare. If you do not have private insurance then the amount payable from an uninsured patient for a complex operation may be anywhere from $10,000 – $30,000 upwards!

The health fund rebate again depends on the type of health fund you are a member with since the rebate amount varies between the health funds. The Medicare and health fund rebates you receive are independent & not determined by your treating surgeon.

Should you feel concerned about the level of your Medicare rebate then please write to Medicare Australia, Federal Health Minister or to your local federal MP regarding this.

Ans: Yes. The Anaesthetist’s fee is different and Dr Nihal has no control on the anaesthetist’s fee. My secretary will give you the telephone numbers of the Anaesthetic group and it is your responsibility to contact them and to ask them an estimate anaesthetic cost for your surgery. Most Anaesthetists charge a gap & you will most likely incur out-of-pocket expenses.

If you are privately insured and have full private hospital cover then generally hospital admission, theatre fees, theatre prostheses, metal plates and screws used, nursing care in the ward, meals etc are all covered. You may have to pay the hospital access to your health funds if you have any access on your policy. Please ask the hospital and your health funds regarding this. You may incur small extra expenses for radiology, pathology, pharmacy and the use of newspapers/ internet/ telephone etc. Please ask the hospital reception staff regarding this.

Ans: We issue standard medical sickness certificate or a certificates of attendance free of charge to all patients. However other claim forms as mentioned above usually take considerable time to complete and will therefore incur a small fee. Please ask our staff for the current fees for completing these forms.

Ans: Dr Nihal only provides a private service. Dr Nihal does not have admitting rights in public hospital. If you agree to have surgery by Dr Nihal then this will be carried out in the Private hospitals.

We accept Visa, MasterCard, EFTPOS or cash. The consultation fee is paid on the day of consultation and the total surgery fee or permissible health funds gap is payable 5-7 days in advance before the surgery date. This can be done over the phone. We do not accept American Express or Diners Club cards.

Unfortunately we cannot tell you the exact costs for the out-of-pocket expenses until Dr Nihal sees you in the clinic and decides which operation and what item numbers are the most appropriate for your case. We are therefore unable to provide you with any quote for surgery until after the clinical consultation with Dr Nihal. Once you have decided to proceed with surgery then we will provide you with an approximate quote for surgery along with associated costs and approximate rebates from Medicare /health funds.

The clinic letter and your medical information is a confidential document and we cannot discuss this with any third person or party or send details via email. My clinic letter is written in response to a request from your GP/specialist & this will only be sent to your GP/Specialist & other allied health professionals who are treating you or who will be treating your medical condition.

The clinic letter is only to be used for medical treatment purposes and cannot be used as a medicolegal letter or for any other purposes to gain income protection or to obtain a disability certificate etc.

If any third party requests any medical information/medical records for the treatment you received under my care  , then they should obtain written consent from you and send it to my office with a request letter along with and applicable fee , which currently ranges from $50 , $70 , $100 to $150 and paid in advance.

If your solicitor./Insurance policy would like a medical report then they should contact my office with your written consent. Fees for medical reports vary depending upon the complexity of the case, size of medical records and the time consumed to prepare medical reports.

My clinic letter is a communication between myself and your treating doctors about your medical condition. Dr Nihal writes this letter to your GP in medical language often containing complex medical jargon which a non-medical person may not be able to correctly interpret, understand or comprehend. Thus the patient may misinterpret… I would therefore suggest that the patient visits his/her GP to discuss Dr Nihal’s letter so that the GO can translate  the medical language into plain English & relay the correct information to the patient.

However, If you would like your clinic letter, then please send a written request to our office and we will post it to you. If the clinic letter contains too much medical jargon the Dr Nihal will include a simple translation. As this involves extra time for both my staff and myself, a small fee would be incurred.

Ans: Please read carefully Queensland temporary disable parking permit guidelines written on the permit application form which says that temporary disability has to be for 6 months, before you qualify for a temporary permit. As most of the fractures in foot/ankle heal in around 3 months. most patients do not qualify for a temporary disabled parking permit.