Inpatient vs. outpatient care: What is the difference?

Roman Danaev

19 December 2024

When you receive treatment, whether from the NHS or a private doctor, it usually falls into one of two categories: it’s either on an inpatient or outpatient basis.

Understanding these terms is very important for your health insurance because some private medical insurance plans only cover one or the other, while some include both. So, it’s good to know what you’re actually covered for. If you’re trying to figure out how inpatient and outpatient care differ, let’s break it down.

What’s the difference between inpatient and outpatient cover?

Here’s an outline of the main differences between inpatient vs. outpatient care:

Coverage

Inpatient care includes hospital services for surgeries, serious medical conditions, or childbirth. Private health insurance plans usually cover all necessary treatments during a hospital stay, which encompasses hospital room and board, hospital staff, and medications.

On the other hand, outpatient care covers treatments that don’t require you to stay in a hospital overnight. This includes consultations, minor diagnostic tests, minor surgeries, and rehabilitation therapies. PMI policies usually have limits on the number of outpatient treatments covered each year.

Duration of treatment

Inpatient treatment lasts as long as necessary based on the patient’s condition. This ranges from a few days to several weeks, depending on the severity of the illness or the complexity of the surgery.

Outpatient treatments are shorter — like brief appointments or sessions that last from a few minutes to a couple of hours, with patients usually returning home the same day.

Location of treatment

Inpatient care takes place in a hospital setting, where patients are admitted and closely monitored by healthcare professionals around the clock. Meanwhile, outpatient care occurs in clinics, general practitioners’ offices, or specialised outpatient facilities. Patients visit these locations for their appointments and leave after receiving care.

Costs and claims process

Inpatient care can be quite pricey because of ambulatory care fees, surgery expenses, and longer stays. Most of the time, though, the hospital handles the claims directly with your insurer.

In contrast, outpatient care usually costs less per visit, but those expenses accumulate quickly if you have several appointments. In many cases, you might have to pay out of pocket first and then file for reimbursement later, depending on your insurance policy. Just remember to keep all your receipts and any medical documents handy for the claims process.

What is inpatient cover?

Inpatient care is when a patient stays in the hospital for at least one night. This type of care is included in most health insurance plans, so you’re covered for serious medical needs.

There’s also day-patient care, which is a middle ground between private inpatient treatment and outpatient services. With day-patient care, you have a procedure and go home the same day. This option is great for treatments that are serious but don’t need an overnight stay, which allows you to get the care you need without a lengthy hospital visit.

What’s included in inpatient cover?

Typical inpatient treatment costs covered by health insurance policies include:

• Surgical procedures
• Accommodation in private inpatient facilities
• Medical tests
• Aftercare services
• Medications and dressings
• Specialist treatment fees
• Anaesthesia fees
• Prosthetics
• Cancer care, including drugs and biological therapies
• Diagnostic tests and scans

Limitations and exclusions

Here are some considerations when it comes to private inpatient care:

• If you were diagnosed with a condition before your policy started, it won’t be covered.
• Some treatments, like experimental procedures, cosmetic surgery, and alternative therapies, might not be included.
• There could be a waiting period before you can claim for certain treatments.
• There might be limits on how much you can claim for certain treatments within a specific time.

What is outpatient cover?

Outpatient care includes all those doctor visits and treatments where you go home the same day without needing to stay overnight in a hospital. Many health plans don’t automatically cover these services, but you can usually add them to your policy — just keep in mind that this increases your premium.

What’s included in outpatient cover?

Examples of treatments typically provided while you’re an outpatient:

• Visits to specialists for expert advice
• Blood tests and X-rays
• MRIs, PET scans, and CT scans
• Radiotherapy or chemotherapy for ongoing medical care
• Physiotherapy
• Chiropractic care for back and joint issues
• Mental health support and psychiatric services
• Annual check-ups

Limitations and exclusions

If outpatient treatment is included in your plan, there could be some limits on what’s covered:

• A cap on the total number of consultations or treatments per year.
• Exclusions for pre-existing conditions or certain chronic diseases.
• Restrictions on specific tests or procedures, such as experimental treatments, certain diagnostic tests (genetic testing, specific biopsies, advanced imaging), chiropractic treatments, mental health services, and alternative therapies.
• A requirement for referrals from your general practitioner before seeing a specialist.

Inpatient and outpatient cover for cancer treatment

You need to understand the inpatient and outpatient services you’re eligible for when it comes to cancer treatment. Of course, read the fine print of your policy. In most cases, inpatient care should cover surgery and certain types of chemotherapy that require hospitalisation for monitoring. During your hospital stay, your insurance usually covers expenses like your room, specialist consultations, and any necessary medications.

Outpatient care includes follow-up appointments, routine scans, and therapies like physiotherapy and counselling. Some insurance plans have limits on how much you can claim for outpatient treatments, but many insurers recognise the importance of ongoing care for cancer and offer adequate coverage for these services.

Do you need both inpatient and outpatient cover?

Inpatient services are usually part of health insurance plans, so the main choice is whether to add outpatient coverage. Even though this will increase your premium, it also helps you avoid delays in both inpatient and outpatient care.

If you don’t include outpatient cover, you’ll have to wait for diagnostic tests and scans through the NHS before getting private inpatient care. Skipping outpatient coverage is certainly a way to save money, but it could mean longer waits when you need care. So, it depends on what you value more.

Does all health insurance cover inpatient and outpatient care?

Practically, any health insurance plan will cover inpatient treatment. On the other hand, outpatient coverage gets a bit more complicated, as not every basic health insurance policy includes it. Some do offer outpatient care but come with limits on how much you can claim each year. Others are more generous and provide unlimited outpatient coverage.

If you choose a health plan with a limit on outpatient treatment, once you hit that cap, you’ll have to pay for any additional treatments yourself. Of course, you can always rely on the NHS if that happens.

Why is health insurance more expensive with outpatient treatment?

When insurers calculate your premiums, they look at many different factors to estimate how likely you are to make a claim. Some of these factors are personal, and others are more general trends in healthcare. Typically, this means that plans, including outpatient cover, will be a bit pricier.

What factors do insurers consider when offering inpatient and outpatient cover?

The chance of needing inpatient care for a serious illness or major surgery is usually lower than needing outpatient services like physiotherapy or minor procedures. Most of us will likely require some basic diagnostic tests in our lives, whereas severe injuries are much less common. Interestingly, outpatient treatment can go on for a longer time, which makes it harder for insurers to predict costs.

Can I choose to include or exclude outpatient cover in my policy?

Yes, outpatient coverage isn’t usually part of standard health insurance, so you can decide if it’s something you want. Just keep in mind that adding outpatient cover will raise your total premium compared to just having inpatient care alone.

Here is how it works at Bupa:

Comparing health insurance providers

When it comes to inpatient or outpatient care, not all plans are created equal. Each provider offers a range of options, from basic coverage to comprehensive plans, along with extras that you can mix and match.

For example, a young, healthy person might choose a basic plan with lower premiums, but a couple planning for a family might want more coverage. Without comparing, you could end up underinsured or overpaying for coverage you don’t need. Plus, looking at different plans is one of the easiest ways to save money.

Final words

Hopefully, we’ve clarified the differences between inpatient vs. outpatient. Just to reiterate: inpatient treatment involves staying overnight in a hospital for serious medical issues or specialised care; outpatient care lets you receive medical treatment and return home the same day.

Most health insurance policies don’t automatically cover outpatient services, but adding this option can be a smart choice. There are benefits and drawbacks to including outpatient coverage, so it’s up to you to decide what best fits your health insurance needs.