Inpatient vs Outpatient
It can be tricky to determine, at times, what is covered by Original Medicare and what is not. For instance, although Original Medicare has hospital insurance (Part A) and medical insurance (Part B), whether or not those insurances will cover hospital stays and procedures depends in large part on whether or not the patient is inpatient or outpatient. Beneficiary’s hospital status determines how much services cost in hospital, as well. To help clear things up, here are three real-life examples of what is covered and when:
Susan goes to the ER with chest pain. She is then formally admitted to the hospital under a doctor’s orders.
Inpatient vs Outpatient?
In this case, Susan is an outpatient until she is formally admitted under the doctor’s orders, after which she is inpatient. Her Part A insurance would pay for her inpatient hospital stay and all related outpatient services provided in the three days before she was admitted. Part B of Medicare would pay for her doctor services.
Jose goes to the ER with abdominal pain. The hospital keeps him overnight in observation, and then a doctor writes an order for admission on the second day.
Jose would be inpatient after the doctor writes the order for admission on the second day, and his Part A hospital insurance would cover accordingly, including the outpatient services in the three days before admission (the overnight observation). Additionally, his medical insurance (Part B) would cover his doctor services.
Laura is in the hospital for an outpatient surgery, but then is kept overnight due to high blood pressure. The doctor does not write an order to admit her, and she is released the next day.
In this case, Laura is never an inpatient, and her hospital insurance would cover none of those services she used while on overnight observation. However, her Part B insurance would cover her doctor services and all relevant outpatient services she received at the hospital.
These examples provide some real-life stories to help clarify what is covered by which part of Medicare and when, so you can best help your clients understand their benefits.
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