One of the most important concepts in private health insurance is the difference between inpatient and outpatient treatment.
Understanding the difference helps explain how hospital cover, extras cover and Medicare work, including why some treatments are covered differently to others.
This article explains what inpatient and outpatient treatment means and why the difference matters for private health insurance.
Key Points
- Inpatient treatment means you are formally admitted to hospital.
- Outpatient treatment is medical treatment received without being admitted to hospital.
- Hospital Cover is designed to cover inpatient hospital treatment.
- Many outpatient services are covered by Medicare or extras Cover instead.
What is inpatient treatment?
Inpatient treatment involves being formally admitted to hospital for medical treatment or procedures.
This can include overnight stays in hospital as well as same-day admissions where treatment is performed and you are discharged later that day.
Examples of inpatient treatment can include surgeries, joint replacements, pregnancy and birth related admissions and other procedures performed in hospital.
Hospital Cover is designed to help cover the costs associated with inpatient hospital treatment.
What is outpatient treatment?
Outpatient treatment is medical treatment received without being formally admitted to hospital.
This can include services such as GP appointments, specialist consultations, scans, blood tests and dental appointments.
Depending on the service, outpatient treatment may instead be covered by Medicare or Extras Cover.
Why does the difference matter for private health insurance?
The difference between inpatient and outpatient treatment is one of the main reasons people are sometimes surprised by unexpected out-of-pocket healthcare costs.
Many people assume their hospital cover applies to all treatment related to a hospital procedure, however services such as specialist appointments, scans and tests received outside of a hospital admission are usually treated as outpatient services.
This also applies when attending a private hospital emergency department, where treatment is initially considered outpatient, with the cost only partially claimable through Medicare. If you then need to be formally admitted to hospital, that’s where your private health insurance kicks in.
Are outpatient services covered by Medicare or Extras Cover?
Many outpatient services are partially covered by Medicare, particularly services such as GP appointments, specialist consultations and diagnostic tests.
Some outpatient services may also be covered by Extras Cover depending on the treatment and your level of cover.
For example, services such as physiotherapy, dental and optical are commonly claimed through Extras Cover rather than Hospital Cover.
Even when Medicare or Extras Cover applies, there can still be out-of-pocket costs depending on the provider and treatment.
Common examples of inpatient and outpatient treatment
| Inpatient treatment | Outpatient treatment |
|---|---|
| Overnight hospital stays | GP appointments |
| Same-day hospital procedures | Specialist consultations |
| Surgery performed after admission to hospital | Scans and blood tests |
| Pregnancy and birth admissions | Dental, Physiotherapy appointments |
| Rehabilitation admissions | Private hospital emergency department visits before admission |
Why is this important to understand?
Understanding the difference between inpatient and outpatient treatment can help you better understand how private health insurance works and reduce the chance of unexpected healthcare costs.
It also helps explain why some services are covered differently depending on whether you are formally admitted to hospital.
If you’re comparing cover options, you can explore Phoenix Health Hospital and Extras cover options online or call our team on 1800 028 817 and we’ll be happy to help explain how different types of cover work.
