An outpatient procedure is any sort of medical treatment done outside of a hospital admission – this could be in a doctor’s surgery or specialist’s clinic and can include things like x-rays, injections and skin treatments.
Even if you go to a specialist’s rooms in a hospital for a consult or treatment, if you are not admitted into the hospital, it will be considered an out-patient procedure.
In-patient services are received whilst you’re admitted into hospital.
If you’re admitted as a private patient, as long as the treatment you receive is included with your Hospital Cover, you will be able to claim up to the Medicare Benefits Schedule (MBS) fee. Learn more about the Medicare Benefits Schedule.
For example, you’ve got a complex skin cancer on your arm that you’ve been told will need to be removed under anaesthesia in hospital. When you go to hospital for your surgery, you’ll be admitted as an in-patient.
Out-patient services are treatments received outside of a hospital admission.
Any treatments you receive as an out-patient are not claimable under private health insurance. Out-patient services are generally claimable through Medicare and can include medical procedures performed in a doctor’s rooms, pathology tests and scans.
For example, you need to have a small skin cancer removed from your arm. Your plastic surgeon will do this in their treatment rooms as an out-patient procedure. As you are not being admitted into hospital, you’re considered an out-patient.
To make sure you have all the information you need to make the right decisions for yourself, we recommend asking your specialist these questions:
- What item numbers will you be using for my procedure?
- Can you provide me with a full breakdown of fees (also known as Informed Financial Consent) for my treatment?
- If I need a medical device or human tissue product, what will my out-of-pocket expenses be?
- Will I need any other diagnostic tests?
Do you need to get a second opinion?
Even if you’ve seen a specialist, if you’re not feeling comfortable with the doctor, your diagnosis and treatment options, or the costs quoted, get a second opinion. It happens more often than you’d think and is a good idea, so you can have all the information you need to make the right decision for you.
As there are no private health insurance benefits available towards out-patient procedures, depending on your doctor, you may experience some out-of-pocket costs.
For medical services recognised by Medicare, there is a Medicare Benefits Schedule (MBS) fee. This is the fee set by the Australian Government for each medical service. Doctors can choose to charge above the MBS fee, which may result in an out-of-pocket cost. If you receive a bill for your treatment, get in touch with Medicare to find out whether you can claim a benefit towards the cost.
Discharge medications
When you leave hospital after your procedure, you’ll often be given discharge medications to continue your treatment at home. There is no benefit payable on discharge medication under your hospital cover, so you won’t be able to claim these costs as part of your hospital admission.
If you hold Extras cover, you may be able to claim a portion of the cost of your discharge medications. We can check this for you – just give us a call.
Post-op doctor appointments
Once you’ve left hospital, it’s important to know that any follow-up appointments you may have with your specialists are considered an out-patient service and are not claimable through your private health insurance. You may be able to claim a portion of the cost of these appointments through Medicare.
Need assistance before, during or after a hospital admission?
Our Health Support Programs are designed to give eligible members extra support when they need it. From hospital and recovery support to mental health, chronic conditions, pregnancy and early parenting, and joint and mobility support, our programs can help you manage your health and recovery.
Programs are delivered by health professionals, often in conjunction with your treating doctors, and are available to eligible members with Phoenix Health hospital cover.
Explore our Health Support Programs to learn more about the support available and eligibility requirements.
Taking a little extra care of your health right after you’ve had a procedure is so important, and while you can’t claim for out-patient specialist visits, there are other ways your health insurance has your back.
Have Extras Cover?
If you hold Phoenix Health Extras Cover, you may be able to claim a benefit towards allied health services that can help with your recovery, like physiotherapy, remedial massage, occupational therapy and chiropractic, as well as Aids to Recovery for items like toilet seat raisers, pregnancy recovery pants, wigs after cancer treatment and bras after a mastectomy. You should refer to your Product Information Sheet for your level of cover or get in touch with a Phoenix Health team member to check your eligibility and find out how to claim.
Our Health Support Programs are designed to help you through your hospital experience and recovery. We want you to feel confident and supported, so you can get back to enjoying life sooner. Explore our Health Support Programs to learn more about the support available.
