Treatments & procedures

Inpatient vs outpatient services, and what you can claim on your health insurance

We explain the difference between inpatient and outpatient hospital services – what you may be able to claim for and when health insurance can’t cover you. 

Lucy E Cousins
November 2018

Knowing whether you’re an outpatient or an inpatient is important if you’re having hospital treatment and have private health insurance.

Health funds are (generally) unable to cover outpatient services. And as having a test, procedure or consultation in a hospital doesn’t necessarily mean you’re an inpatient, this is a common source of confusion, and frustration.

HCF’s Ann O'Gorman Skarratts sheds light on the issue.

What’s the difference between an inpatient and outpatient service?

“[An] inpatient service is any service you have once you’ve been formally admitted to a hospital. As either a day or overnight patient. So outpatient is anything where you’re not formally admitted to hospital.”

What’s an example of an outpatient procedure?

“The most common outpatient procedures are going to hospital for tests, attending an outpatient clinic, or having consultation in hospital with a specialist. It’s not until you fill out all the admission paperwork and are formally admitted that you change over to inpatient services.”

Are there any exceptions to this?

“Yes, the main exception is if you’re in an emergency department – you’re still considered an outpatient while you’re there. This is the same for private and public hospitals.”

Why is it that you can only claim for inpatient services?

“Health funds, by legislation, aren’t allowed to pay for any outpatient service where Medicare pays a benefit.”

Why don’t we pay when we go to an emergency department?

“If you go into a public emergency department as a public patient, the government has already funded those services, so you can’t be charged anything. You’ll be treated free of charge if you’re eligible for Medicare.”

When you’re being admitted to hospital, when should you ask about costs?

“You should always ask about costs upfront anytime you see a doctor or go to a hospital.

“If you’re admitted to hospital, the hospital will often tell you about their costs, but they won't have the information about specific doctors or specialists. Often there may be an anaesthetist or an assistant surgeon involved that you might not be told about upfront, so ask for a full list of costs and if there’s anybody else involved that you need to know about.” 

If you’re not sure what you’re covered for, or need advice on hospital costs, call us on 13 13 34. 

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