What is the difference between inpatient and outpatient procedures and how does it affect your health insurance?
If you suffer an injury or illness and go to hospital for treatment, whether or not you are admitted to hospital will have a huge bearing on the cover provided by your private health fund. While hospital cover provides financial protection for treatment you receive as an inpatient, it does not cover the cost of treatment you receive as an outpatient. However, it’s essential to compare cover features and exclusions before choosing an insurance policy to ensure that you know exactly what will and won’t be covered by your health fund.
What is outpatient care?
An outpatient is someone who receives medical treatment without actually being admitted to hospital. Most commonly outpatient clinics are located in public hospitals but care is sometimes provided in private hospitals, a doctor’s consulting rooms or community health centres. Outpatient services includes a range of procedures, including emergency department treatment of injuries, mental health services and X-rays. Procedures and services classed as outpatient care include:
- Emergency ward treatment without the patient being formally admitted
- Consultations with specialists to determine the most appropriate treatment for a patient
- GP visits
- Antenatal consultations with an obstetrician
- Diagnostic services such as pathology, X-rays, ultrasounds and other organ imaging
- Dispensing medication
- District and community nursing services
- Mental health and other outreach services
- Drug and alcohol services, including group sessions
What is inpatient care?
Inpatient care is when patients receive treatment during a stay in the hospital. The stay in hospital can be either overnight or just a day admission, and the patient must be formally admitted to hospital to be classed as an inpatient. This means that even if you visited an emergency room and were asked to stay overnight for observation, you still would not be classed as an inpatient. Inpatient care tends to cover a range of more serious services and procedures, such as:
- Emergency room patients who are admitted to hospital
- Intensive care
- Surgical treatment for a wide range of injuries or conditions, for example heart surgery, joint reconstructions and appendix removal
- Some cancer treatments
- In-hospital pharmaceuticals
What types of outpatient benefits are covered?
When you receive treatment as an outpatient, in most cases you will not be covered by private health insurance. You will instead need to rely on cover from Medicare, which provides benefits for things like GP visits, specialists’ consultation fees, X-rays and pathology, and eye tests performed by optometrists. Medicare covers 85% of the Medicare Benefits Schedule (MBS) fee for visits to the doctor that occur outside hospital, but if you visit a doctor who bulk-bills then you may not have to pay a cent. However, it’s worth pointing out that some other health care services you receive outside of hospital can be covered by an extras policy. These include:
- Dental exams and treatment
- Glasses and contact lenses
- Physiotherapy and chiropractic treatment
- Speech and occupational therapy
- Hearing aids
- Natural therapies, for example acupuncture or naturopathy
What types of inpatient benefits are covered?
Private health insurance hospital cover policies are designed to pay benefits on a wide range of treatments you receive as a hospital inpatient. While the exact list of procedures and services covered varies depending on the level of cover you choose, most Australian private health funds pay benefits to cover the following inpatient medical costs:
- Hospital accommodation, including for day surgery and overnight stays
- Theatre and surgical fees
- Doctors’ and specialists’ fees
- In-hospital pharmaceuticals and dressings
- Surgically implanted prostheses
- Intensive care
- Diagnostic tests
A top hospital policy will provide cover for all the inpatient procedures and services for which Medicare pays a benefit, while mid and basic hospital policies will restrict or exclude high-cost procedures. You may also get to choose the hospital where you are treated and take advantage of treatment in a private hospital, or as a private patient in a public hospital.