Are You Getting Inpatient or Outpatient Care? A Question with Big Consequences
If you become a hospital patient, it will be important to know the answer to this question: What’s the difference between inpatient versus outpatient care? Even though inpatient and outpatient services might be very similar, your status as a patient will significantly affect your cost, time in the hospital and ultimate course of care.
To become an inpatient you must be formally admitted to a hospital by a doctor. This means your stay has been ordered at the request of a physician.
Outpatients can be in a hospital getting medical treatment, however, they are not formally “admitted” until their treatment and a possible 24 hours or so of “observation” ends. You remain classified as an outpatient, even if you’ve been rushed there by ambulance until a doctor requests that you be “admitted” as an inpatient.
Several factors distinguish inpatient from outpatient care. One factor is the length of your visit. Inpatients typically are ordered by their doctors to spend more than 24 hours in the hospital while being monitored. Outpatients, on the other hand, typically leave after only a few hours when their procedure or monitoring is finished.
By learning the differences between outpatient and inpatient care, you’ll better understand your next hospital-related bill. Your plan’s Summary of Benefits and Coverage document will provide the key details differentiating the two classifications.
Tips on What Defines “Inpatient” Care The following medical services generally fall under inpatient care:
- Major surgeries
- Complex medical treatment, including an overnight stay at the hospital
- Childbirth
- Care, including medical detoxes, at certain psychiatric and substance use facilities
Once you’re admitted as an inpatient, medical staff will be on hand until you’re discharged. Regardless, the length of your inpatient insurance coverage may vary significantly, depending on your health plan. For example, some plans limit coverage times for childbirth, meaning that your insurance may only pay for maternity inpatient care of fewer than 48 hours or so.
Tips on What Defines “Outpatient” Care
Most other services are deemed outpatient services, including:
- Routine checkups
- Visits with a specialist
- Lab tests
- X-rays, MRIs, and CT scans
- Minor surgeries
- Same-day rehabilitative services, such as physical therapy
- Emergency services, up to the point you are formally admitted as an inpatient needing further treatment, not just observation
As an outpatient, you generally won’t stay overnight at the hospital. Your doctor will send you home after your treatment.
Health Insurance and Inpatient vs. Outpatient Care
Under the Affordable Care Act (Obamacare), inpatient and outpatient care are included as essential health benefits (EHBs) that all ACA insurance plans must cover. That means your copayment or coinsurance will be only a fraction of the costs for either type of care.
Ambulance service will likely be covered if your ride is deemed medically necessary by your health insurer. Still, your insurer may cap what it will pay at around $150 to $250 a trip. Check your policy or call your insurance company to learn more, including your nearest hospitals and urgent-care facilities in your provider network, and therefore the least costly.
Copayments for inpatient care will mount depending on the duration of your stay and the complexity of your treatment. Outpatient services very often cost less than inpatient care because individuals don’t need close supervision. Whether you’re an inpatient or outpatient, your overall out-of-pocket expense for your care will be a portion of whatever is billed to treat you.
Defining “Under Observation”
If a doctor puts you “under observation” at the hospital, you are still classified as an outpatient. Your doctor may need to run tests and closely observe you. You will usually be “under observation” for 24 hours or less, but that classification can stretch beyond that time frame, depending on your doctor’s concerns about your condition.
At that point, you are an inpatient.
Urgent Care Clinics: Outpatient Care Without a Hospital
Urgent care clinics offer outpatient care – and only outpatient care – for non-critical emergencies. If you go to an urgent care center, you may save an unnecessary trip to the ER as well as the considerable costs for an ambulance and emergency services.
A medical professional at an urgent care center may send you to a hospital emergency department, depending on the severity of your injury or illness. If this happens, you will have to pay the urgent care center costs for outpatient care. Those bills will be n addition to any hospital costs you incur.
You Are Always an Inpatient at Skilled Nursing Facilities
Skilled Nursing Facilities (SNFs) care for patients onsite 24 hours a day, so anyone in an SNF is considered an inpatient. From physical therapy to illness recovery services, facilities provide different long-term care options, depending on the patient’s needs.
As a hospital inpatient, you may be well enough to leave the hospital but not well enough to return home. In that case, you may be referred directly to an SNF, where you will receive continuous, quality rehabilitative care. Sometimes the SNF may be right down the hall or an elevator ride from the hospital itself.
Under Obamacare, many plans cover SNF stays for a limited number of days based on medical necessity. Check your insurance policy for the specifics. If you or a loved one needs an SNF, research the best facility that participates in your health plan’s network. You can get an overview of SNFs in your area at the Medicare site.
Ultimately, your doctor will decide whether you need inpatient or outpatient services. And your health plan will cover the majority of those costs, whether you need inpatient or generally less-expensive outpatient care
