As a patient, you’ll eventually ask: what’s the difference between inpatient versus outpatient care? Even though inpatient and outpatient services might sound similar, each have different levels of cost, time, and care.
Inpatients are formally admitted to a hospital by a doctor. This means your visit has been ordered at the request of a physician.
Outpatients go for medical treatment, but don’t have to stay for intense monitoring once their treatment is finished. As an outpatient, you’ve entered the building on your own or by an ambulance.
A useful way to distinguish between the two types of care is the length of your visit. Inpatients typically have to spend more than 24 hours at the hospital, and are monitored depending on their condition. On the other hand, outpatients have shorter visits lasting only a few hours. Outpatient visits end soon after your procedure is finished.
By learning the differences between types of care, you’ll be an expert on your next medical bill. The Summary of Benefits and Coverage document that comes with your health plan gives details of your coverage for inpatient versus outpatient care.
What Does “Inpatient” Mean?
The following services generally fall under inpatient care:
- Major surgeries
- Complex medical issues, after which you stay overnight at a hospital
- Certain psychiatric and substance use facilities, including medical detoxes
If you’re an inpatient, medical staff will be on hand for your entire visit until you’re discharged. Depending on your health plan, time extensions for your inpatient stay may vary. For example, some plans come with time limits for childbirth, meaning that your insurance will only cover maternity inpatient stays for a set number of hours.
What Does “Outpatient” Mean?
Most other services are a part of outpatient services, including:
- Routine checkups
- Visits with a specialist
- Lab tests
- Minor surgeries
- Same-day rehabilitative services, such as physical therapy
- Emergency services, until you are admitted as an inpatient
As an outpatient, you won’t stay for a night at the hospital. With your doctor’s approval, you’re free to go home after your visit.
Health Insurance and Inpatient vs. Outpatient Care
Under the Affordable Care Act, inpatient and outpatient care fall under essential health benefits or EHBs. Health insurance companies help cover costs for EHBs, meaning that you’ll only pay a fraction of the costs. This is also known as your copayment or coinsurance.
If you need an ambulance, these costs will also be a factor in your total outpatient visit. If your ride is medically necessary, your health insurer will likely cover this expense. You can look at your insurance policy to learn more about ambulance coverage.
Copayments for inpatient care will depend on the duration of your stay. Outpatient services often cost less than inpatient care because individuals don’t need close supervision from a medical team. The overall out-of-pocket expense for your care will be a portion of what if costs to treat you.
Defining “Under Observation”
If you are “under observation” by a physician, you are still considered an outpatient. Your doctor may need to run a few extra tests and observe you in a hospital setting. You will usually be “under observation” for 24 hours or less, but timelines can vary depending on your condition.
You’re considered an outpatient until your doctor formally admits you to the hospital as an inpatient. Click To Tweet Based on the evaluation, a doctor may admit you to the hospital as an inpatient. However, if you’re released, you will only pay for outpatient services.
Urgent Care Clinics: Outpatient Care Without a Hospital
A physician at an urgent care center can also refer you to the emergency department depending on the severity of your injury. If this happens, you will have to pay costs for outpatient care.
Skilled Nursing Facilities Are Always Inpatient Settings
Skilled Nursing Facilities (SNFs) will care for patients with medical professionals onsite 24 hours a day. From physical therapy to illness recovery services, facilities offer different long-term care options.
As an inpatient, you may be referred from a hospital directly to an SNF. If you’re well enough to leave the hospital but not well enough to return home, SNFs will give you continuous, quality rehabilitative care away from the hospital.
Under the ACA, many plans cover SNF stays for a limited number of days based on medical necessity. You can find your coverage specifics by taking a close look at your insurance policy. If you or a loved one needs a Skilled Nursing Facility, be sure to research the best facility that participates in your health plan’s network.
Ultimately, your doctor will decide whether you will need inpatient or outpatient services by considering your health status. From treatment to extended care, your health plan should address most inpatient and outpatient services.