Inpatient vs outpatient. What’s the difference?

Impatient v outpatient. What's the difference. A man in a hospital bed receiving inpatient care


We know that any medical admission can be daunting. It’s often hard to decipher the terminology used when referring to your admission or how we pay for your treatment. At RT Health we’re committed to taking the jargon out of private health insurance. We want our members to understand their cover, the benefits of private health insurance and some tricky terms when it comes to making the most of your cover. It’s often confusing … and it doesn’t need to be. We often field questions from our members who want to know "what is an outpatient" or “what is an inpatient”, and how it impacts their treatment and their cover.

What’s an inpatient? 

You’re an inpatient once you’re admitted to hospital for medical treatment, observation or for a procedure. Depending on the purpose of your hospital stay, there are different types of hospital admissions (inpatient medical services) that can range from the unplanned (when you’re admitted to hospital through an emergency department) to the scheduled or planned (a day procedure, an overnight or extended stay because of illness and/or treatment or surgery, having a baby).

You’ll become an inpatient once you’re formally admitted to hospital for treatment. This can happen two ways:

  • You’re admitted after attending the emergency department.
  • You’re admitted as part of a pre-booked procedure or course of treatment.

It’s not necessary to stay overnight to be classed as an inpatient. If you are admitted by a doctor and receive treatment you can still be an inpatient, even if it’s only for a day.

What does being ‘admitted’ mean? 

You’re admitted to hospital if and when your doctor decides you need for you to be cared for or treated in hospital. If you’re seriously unwell or injured, you may be immediately admitted to hospital through an emergency department. This is called an emergency admission. 

The other way of being admitted to hospital is a planned admission. It’s when your doctor refers you to a specialist doctor and the specialist recommends you be admitted to hospital for treatment. This generally doesn’t happen straight away and there are often waiting lists for surgery and other treatments.

Types of inpatient 

Planned admission: If your hospital admission is planned, how you’re admitted depends on whether you’re going to a public or private hospital, how urgent your treatment is and the kind of treatment you’ll be receiving.  Once you’re admitted into hospital for planned treatment, you’ll stay in a hospital ward. How long you’ll stay depends on the treatment you need. For minor procedures, you may only need to stay for a day, but for ongoing treatment or major surgery, you’ll need to stay for longer. 

Emergency admission: Going to an emergency department doesn’t automatically mean you’re an inpatient. You can get minor treatments, assessments and tests while being treated at the emergency department, and still be an outpatient. In public hospitals, these services are covered by Medicare (that’s why we can’t cover them under your private health insurance). However, if your treating doctors assess that you need further care and treatment, you may be admitted to hospital – and you become an inpatient.  It’s important for members to know that we’re only able to pay benefits once you’ve been admitted to a hospital (public or private) as an inpatient. Private hospital emergency departments can often issue invoices known as ‘facility fees’ and unfortunately, we’re not able to pay them on your behalf. 

What’s an outpatient? 

You’re an ‘outpatient’ if you receive medical services or treatments without being admitted into hospital. This includes a range of procedures, from specialist appointments, post-surgical follow-up consultations, prenatal visits, diagnostic imaging, pathology, or minor treatment and assessments in an emergency department. When you’re treated in an emergency department, you’re an outpatient unless you are formally admitted into the hospital for further treatment or observation. 

What are outpatient services?

  • medical treatment in a doctor’s surgery
  • consultations at a specialist’s clinic or their rooms at a hospital
  • treatment in a hospital emergency room
  • diagnostic services such as pathology, X-rays, ultrasounds and other organ imaging.

Just because the treatment is happening at a hospital, it doesn’t mean you’ll be admitted as an inpatient. For example, doctors can conduct outpatient treatments at their offices in a hospital or at a medical centre for things like X-rays, chemotherapy, injections, wound dressings, skin treatments, home nursing, non-PBS prescriptions and prenatal classes. 

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

Unfortunately, Australian health funds can’t cover the costs of emergency services or outpatient services. This is because the government pays a benefit (some or all of the cost) for these services through Medicare.

You’ll be covered by Medicare for most outpatient treatments, including things like GP visits, specialists’ consultation fees, x-rays and pathology. There are sometimes out-of-pocket costs for these services. 

Questions? 

We’ve got answers. 
We know that navigating treatment types and costs can often be stressful. Let us help you. 
If you’re unsure about what is and isn’t covered by your health cover, just get in touch. We can help break down your treatment and expected costs for you.

You can call our friendly team us on 1300 886 123 (Monday to Friday, 8:30am-5:00pm AEDT/AEST) or reach out via email to help@rthealth.com.au
We’ll be happy to help.