Inpatient vs outpatient – what's the difference?

We explain the difference between inpatient and outpatient hospital services – what these terms mean when you go to hospital. 

When it comes to going to hospital, it can be confusing to know whether you’re an outpatient or an inpatient, and what’s covered by Medicare and your private health insurance.

We’re here to help you understand the complexities of treatment and the associated costs when you go to hospital.

If you have hospital cover with HCF, you are generally covered for treatment that happens when you are admitted to hospital and sometimes you can also be covered for at-home treatment or in other settings when you leave the hospital.

Health funds are generally unable to cover the cost of services that are payable by Medicare and not provided by a hospital, even if they are provided at the hospital premises – having a test, procedure or consultation in a hospital doesn’t necessarily mean you’re an inpatient, so this is a common source of confusion and frustration.

Here, we answer some of your most common questions about the difference between inpatient and outpatient hospital services when you go to hospital.  

What’s an inpatient?

The main distinction between being an inpatient and being an outpatient is being admitted hospital.

You receive an inpatient service when you’re formally admitted to receive treatment or care in a hospital via the two following ways:

• if you visit the emergency department and are then admitted to a hospital ward; or
• if you’re pre-booked for a procedure or treatment.

What’s an example of an inpatient procedure?

Having surgery is a common form of inpatient care. You might stay overnight or only for the day, depending on the procedure.

The benefit of having private health insurance means you can be admitted to a private hospital and have more choice about your care. You can choose your own doctor and hospital, you may enjoy services like a private room, and potentially avoid long waiting times for elective surgery.

What’s an outpatient?

You’re an outpatient if you go to hospital for treatment provided by someone other than a hospital, and without being admitted to hospital. Having X-rays, ultrasounds and blood tests, GP visits and having a consultation with a specialist are common outpatient procedures.

Even if you are at a hospital for these, they are not hospital treatment unless the services are provided or arranged by the hospital during an inpatient stay.

Are there any exceptions to this distinction?

Yes, the main exception is if you’re in an emergency department, you’re receiving treatment from the hospital but are still considered an outpatient while you’re there and are not covered under your hospital policy.

Once you’re admitted to hospital and moved to a ward, you become an inpatient and receive hospital treatment. It’s the same in both private and public hospitals, although it’s not as common for private hospitals to have emergency departments.

If you have private health insurance, you may be asked if you would like to be admitted to the hospital as a private or public patient. Find out more about the difference between private and public hospitals.

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

You’re classed as an outpatient when you’re in an emergency department and the government will fund these services if you are eligible for Medicare.

“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,” says Ann. “You’ll be treated free of charge if you’re eligible for Medicare.”

If you're admitted to hospital as a private patient, your HCF hospital cover will pay for some of the costs associated with your treatment (if it's covered under your policy) and you may be able to choose your doctor.

Why can you claim for inpatient services and not outpatient services?

Understanding what private health insurance covers can be confusing. Put simply, health insurers can’t offer cover for most outpatient services provided at the hospital premises because Medicare covers some or all of the costs.

“Health funds, by legislation, aren’t generally allowed to pay for outpatient services where Medicare pays a benefit,” says Ann.

However, health insurers can cover extras health services like physiotherapy and podiatry that aren’t covered by Medicare. These are part of extras cover.

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

It’s best to understand the costs of your procedure before you have treatment as an inpatient.

Ask for a written quote and the Medicare number for your procedure, then check to see whether it’s covered under your policy and if you’ll need to pay any out-of-pocket costs like an excess or a gap payment to help you be better prepared.

“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,” says Ann.

“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 an HCF member, choosing a doctor who participates in our gap scheme is the best way to minimise or avoid gap costs. We’ve partnered with hundreds of medical specialists and extras providers, so use our Find a Provider tool to find participating specialists and have peace of mind about your costs before you have treatment or go to hospital.

Members can also use our Find a Participating Hospital tool to reduce your out-of-pocket costs at private hospitals around the country.

Heading to hospital soon?

Understanding your procedure can provide peace of mind. Use our Preparing for Hospital tool to learn how it works, how to prepare, what to expect in hospital and what aftercare you may need. If you’re not sure what you’re covered for, or need advice on hospital costs, call us on 13 13 34. 

Words by Lucy Cousins
Updated August 2022