What's the difference between an inpatient and an outpatient?

When it comes to your health, it’s important not to get confused by jargon – and two terms that are thrown around regularly are 'inpatient' and 'outpatient'.   

 Not only do they mean two very different things but knowing what’s what will help you determine whether you’ll be covered by Medicare or your private health insurance – or whether you’ll have to pay for the treatment out of your own pocket. 

Related: Who pays for what when it comes to your medical bills?

An inpatient is someone who’s been admitted to hospital for medical treatment. The two main ways you could become an inpatient are through a hospital’s ER (emergency room) or through a pre-booked surgery or treatment (such as if you need a knee replacement). 

You don’t have to stay overnight in hospital to be classified as an inpatient. As long as you’ve been admitted by a doctor and received treatment – even if you’re only in for the day – you’ll still be an inpatient.  

But just because you’re visiting your doctor or specialist at a hospital doesn’t necessarily mean you’re classified as an inpatient. Some medical professionals have a room they work from within a hospital. 

We spoke with nib’s Clinical Consultant, Shaun Bowden to help us understand the difference. 

Generally when you’re an inpatient, you’ll be checked into the hospital, be provided a room or a bed and be asked to sign the National Claim form 

If you’re classified as an inpatient and choose to use the public health system as a public patient, you will be covered by the government for the cost of your in-hospital treatment for the duration of your stay if you're an Australian resident or otherwise eligible.  

If you’re eligible to use your private health insurance, you’ll be able to receive inpatient treatment as a private patient. In an emergency, you may be asked whether you’d like to be admitted as a public or private inpatient. It helps to understand the pros and cons for each option.  

For more information, check out our article: Should I use my private health insurance in a public hospital?

The hospital or your doctor will let you know when you’ll be discharged – that’s when you’ll be able to leave the hospital. Once you’re discharged from being an inpatient, you’ll be classified as an outpatient. 

What is an example of an inpatient procedure?

Surgery is the most common inpatient procedure. You may have day surgery or stay overnight depending on the type of surgery you’re having. An endoscopy – where your doctor inserts a thin camera into your body to observe your organs – is another example of inpatient care.

You’ll be classified as an outpatient for any sort of medical treatment in a doctor’s surgery, specialist’s clinic or even in a hospital’s emergency room when you haven’t been admitted to hospital.  

So, even if you’ve been previously admitted to hospital as an inpatient, you’ll be classified as an outpatient once you’re discharged. 

“If you’ve booked an appointment with a doctor or specialist at a hospital for a consultation or an injection with a bill to take to Medicare, you’ll probably be classified as an outpatient,” Shaun explains.  

Some outpatient treatments can be partially covered by Medicare or your private health insurance Extras, but you’ll most likely have some out-of-pocket costs. 

What is an example of an outpatient procedure? 

Outpatient treatments can include things like X-rays, injections, wound dressings, skin treatments, chemotherapy, home nursing, non-PBS prescriptions, physiotherapy and prenatal classes, says Shaun. 

Are there any exclusions when it comes to inpatient or outpatient procedures? 

Inpatient treatment will be covered by a combination of Medicare, your private health insurance hospital cover and you may need to pay for out-of-pocket costs^1. “Your cover may provide a benefit for some outpatient treatments.”  To find out more about what is covered when you go to hospital, read What is covered? 

Are there any advantages or disadvantages to either? 

Out of pocket costs and the process for submitting claims are the main differences, explains Shaun. “If you’ve had inpatient treatment, the hospital will submit the claim to us. If your hospital is a nib Agreement hospital, we’ll manage the claim, so you’re likely to face minimal out of pocket costs beyond your excess. Plus, if your specialist chooses to participate in the MediGap network, it can help reduce or eliminate your out of pocket costs.   “If you’ve seen a health professional and you’re covered by Extras and there was no Medicare claim, send the claim to us and we may reimburse you depending on your level of Extras cover.”

Why can't you claim for doctor visits?  

“When you go to a clinic to see a doctor or specialist as an outpatient, they’ll either bulk bill to Medicare or provide you with the information to submit a claim to Medicare – nib can’t cover you for the consultation if it is covered by Medicare,” Shaun says. 

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

No one likes a surprise bill, so Shaun says it’s a good idea to ask for a quote before you agree to any treatment. “Don’t forget that you can get another opinion and find out more information before you agree to purchase the treatment you’re being offered,” he says. 

“It’s a good idea to contact nib beforehand, too, to ask if you’re covered under your policy. You can also check if the hospital has an agreement with nib to keep out of pocket costs low, and if the doctor participates in MediGap.” 

How long do you need to stay in hospital to be considered an inpatient? 

You can be considered an inpatient even if you’re only in hospital for the day, Shaun says.  

An inpatient is when a doctor or a nurse practitioner makes a clinical decision that you need hospital care to receive treatment, summarises Shaun.  

 “As an outpatient, you can have treatment without being admitted. You may receive treatment ‘in’ a hospital, such as in the emergency department, a consulting room or having a radiology test, but that doesn’t mean you’re admitted. If you’re unsure, ask,” he says.  

 If you’re an nib member heading to hospital soon, make sure you check out our Going to Hospital page. This tool gives you information on health insurance, tips on how to reduce any out-of-pocket expenses and helpful questions to ask your specialist. To find out the details of your current policy, chat to someone about your upcoming hospital visit or get some guidance, call us on 13 16 42.

Please note: The tips throughout this article serve as broad information and should not replace any advice you have been given by your medical practitioner. 

^1Coverage may differ depending on your level of cover and policy exclusions, waiting periods, hospital excess and limits, whether you go to an nib Agreement Hospital, a non-agreement private hospital or a public hospital and whether the specialist participates in nib's MediGap scheme. Out-of-pocket expenses may apply.