The Difference Between Outpatient and Inpatient Services

And what you can claim on your Private Health Insurance

So you’ve fallen ill or busted your knee. You get to the hospital and find that your health fund only covers you as an inpatient for services covered on your policy. So what exactly does this mean?

This issue can cause quite a bit of confusion and frustration when visiting the hospital. It is important to understand the difference between inpatient and outpatient services and when your health fund will pay a benefit towards your treatment. Health Deal can explain this in more detail:

Doctor taking an in patient's pulse

What is an Inpatient Service?

If you choose to use the public health system as an inpatient, your hospital costs will be covered by Medicare. If your hospital policy qualifies you to use your health insurance, you can be admitted as a private patient.

You are considered an inpatient when you’ve been admitted into hospital for treatment. Usually, this is done when you are pre-booked for surgery or when you visit the ER in critical condition. Visiting a doctor or specialist in the hospital doesn’t automatically make you an inpatient.

As a general rule, you’re counted as an inpatient when your doctor books you for admission into a hospital bed or room, provide you with a hospital gown and brings you the National Claim Form to fill in.

Private Health Insurance will cover your treatment as long as it’s a service included on your hospital policy and you’ve served your waiting periods. Unsure of what you’re covered for or looking to improve your cover? Call Health Deal on 1300 369 399

Usually, when you’re brought into the ER, the administration staff will give you the option to be admitted as a private or a public patient. Private patients can choose their own doctor as long as he/she has practicing rights at the hospital and you can request to be placed in a private room subject to availability. Private patients generally get a few extra hospital perks such as TV, access to Wi-Fi and a wider range of meal options.

If you have the appropriate level of cover for your treatment, you can take advantage of the benefits of being treated in a private hospital, have a wide range of choices regarding which hospital you stay in and get to choose your own doctor or surgeon. A top or gold hospital policy will provide financial cover for every inpatient service that Medicare pays a benefit toward, whilst a mid and starter hospital policy will limit or exclude higher-costing procedures.

Being admitted as an inpatient doesn’t necessarily mean you’ll be in hospital overnight. You can receive treatment or be booked for a day surgery such as cataract removal from the eye and then be released a few hours later.

Your doctor or medical team will advise you on your discharge dates. Once you are released from hospital you’re considered an outpatient.

What is an Outpatient Service?

The main difference between an outpatient and inpatient service is when you are just visiting the hospital without being formally admitted.  

Therefore, if you receive any medical treatment in an emergency room, in a doctor’s surgery or in a specialist’s clinic where you haven’t been admitted, this is determined as an outpatient service.

Some common outpatient procedures include:

  • X-rays
  • Ultrasounds
  • Wound dressings
  • Injections
  • Physiotherapy
  • Skin treatments
  • Dialysis
  • Colonoscopies
  • Alcohol and drug services, which can be group sessions
  • Home nursing
  • Chemotherapy
  • Non-PBS pharmaceuticals
  • Pre-natal classes

If you’re being seen as a public patient, Medicare will cover a portion of your outpatient bill following a co-payment.

If you have private health insurance, some of these treatments will either be fully or partially covered by your health fund depending on your level of extras cover. Not sure about your extras cover and want to review your policy? Health Deal can help you do this in a matter of minutes.

Even with private health insurance, you can still rely on the Medicare rebate for things like GP visits, X-rays, and specialist consultation fees.

Here are some of the common outpatient services that can be found on an extras cover:

  • General and major dental
  • Physiotherapy
  • Chiropractor
  • Prescription glasses and contact lenses
  • Hearing aids
  • Speech and consultation therapy
  • Natural therapies (Acupuncture, Naturotherapy)

Consequently, whether you are seen as a public or private outpatient, expect some out-of-pocket expenses. Knowing the difference between an inpatient and outpatient service can help you make informed financial choices when visiting the hospital and whether you choose to be admitted as a public or private patient.

Interested in private health insurance? If you would like to find a hospital or extras policy, perhaps even a combination of both to suit your medical requirements, Health Deal can help.

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