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Inpatient vs. Outpatient

When you or a loved one are admitted to the hospital, it can all be very overwhelming and emotional. In this difficult time, it is important to maintain a clear head and get clear answers. One of the most important things to find out is if you are actually admitted to the hospital as an “inpatient” or if they placed you in observation status also known as “outpatient.” This is extremely important for a few reasons that we will dive into together.

What is observation status?

When you are admitted to the hospital, you are either an ‘inpatient’ or an ‘outpatient’. Inpatient means that you have a serious medical problem that requires a high level of care that you can only receive in the hospital. Outpatient, or observation status, means that you have a condition that could possibly get worse so doctors want to monitor you to see if you require hospital admission.

To make things even more confusing, patients can be in ‘observation’ in the ER department for more than 24 hours. Medicare defines an ‘inpatient’ as someone who stays in the hospital for at least 2 nights. Some people assume they are admitted to inpatient because they are in a hospital bed or a private room, but that is not always the case.

How are inpatient and outpatient determined?

The guidelines are very complex and they change every year. Some situations are spelled out clearly but sometimes it is up to interpretation. Most hospitals and insurance companies have someone review their guidelines to determine what cases should be observed. Each individual usually has a case manager or a review nurse that will use a system to review each case to determine what status they qualify for while they are admitted to the hospital

How does this affect insurance costs?

Depending on what status you are admitted, that will determine which part of your insurance will cover the costs. When you are an inpatient, your hospitalization benefits will cover it. When you are under observation, your outpatient benefits will cover the cost, and that can be troublesome. Outpatient coverage is usually less coverage and it does not typically cover procedures or treatments that are common in the hospital setting.

The other tricky part of this is when you are leaving the hospital. If you are on Medicare and you are being discharged from the hospital and moved to a skilled nursing facility, you must have stayed as an inpatient for 3 days prior to being moved to the skilled nursing facility. If you are not there for 3 days, or if you are admitted under observation status or outpatient, you will not qualify for free skilled nursing treatment and you will be responsible for paying the entire bill out of pocket.

How can I find out if I’m inpatient or outpatient?

It’s easy, ask your physician. If the physician does not know or cannot tell you, speak with the case manager that is assigned to your case. This clarification can help you avoid any surprises later when you receive your bills.

One of the leading causes of personal debt in the U.S. is healthcare costs. Some ways to prevent this from happening to you is to make sure that your health insurance will cover your costs whenever you are admitted to the hospital.

Nan Wetherhorn can help go seamlessly through all steps of the way via the affordable care packages