If you’re staying overnight in the hospital, you’re an inpatient. If you’re at the hospital receiving care for the day, you’re an outpatient. Right?
Wrong. Those common-sense definitions aren’t the ones Medicare uses. Knowing what Medicare actually considers inpatient vs. outpatient could save you thousands of dollars.
The difference for Medicare hinges on whether a patient is admitted to the hospital or simply there for observation. According to Medicare.gov, “You're an inpatient starting when you're formally admitted to the hospital with a doctor's order.” You’re an outpatient if you’re receiving services in the hospital–including ER care, observation services, outpatient surgery, lab tests, and any other care–when “the doctor hasn't written an order to admit you to a hospital as an inpatient. In these cases, you're an outpatient even if you spend the night in the hospital.”
“The distinction between observation and admission has clinical and ethical implications for patients and practices,” according to Dr. Laura Haselden and Dr. Sabrina Rahman in a 2023 article in the AMA Journal of Ethics called “Cheating the Rules of Admission with ‘Observation.’” For physicians, there’s often no meaningful difference between a patient who needs care for at least two midnights, and one who likely needs care for more than two midnights. The former should be admitted, while the latter can remain under simple observation. And yet when doctors make that key call, they’re initiating potentially major financial consequences for the patient.
While patient advocates fight to make this process more transparent for everyone, protect your own finances by understanding the difference between admittance and observation.
What Medicare Does and Doesn’t Cover
Even when the actual services rendered look exactly the same, Medicare coverage differs greatly based on whether the patient has been admitted as an inpatient or is being observed as an outpatient. Medicare Part A pays for inpatient services, but not for outpatient services. Part B will usually cover outpatient care, but the patient will pay more than they would for an inpatient stay covered under Part A. And for those who don’t have Part B coverage, the observation (outpatient) services will likely have to come out of pocket.
Importantly, Medicare will only cover care at a skilled nursing facility (SNF) if the patient was admitted to a hospital (i.e., as an inpatient) for at least three days and then discharged to the SNF.
Unfortunately, there’s incentive for hospitals to lean toward observation rather than admittance. Under the Medicare Fee for Service Recovery Audit Program, hospitals might lose their reimbursement if Medicare finds that they admitted someone who didn’t medically need to be admitted. As a result, hospitals tend to err on the side of observing patients if there’s initial doubt that they need to be admitted.
According to Medicare, “The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care.” However, Dr. Haselden and Dr. Rahman counter, “Although observation status is intended as a clinical decision-making tool, it has become more of an all-purpose loophole to artificially improve hospital metrics and pose barriers to inpatient care.”
New Policies Up Patient Protection
The thing is, patients don’t always know when they’ve been admitted versus when they’re just being observed. Even worse, a hospital can change a patient’s status without notifying the patient–even retroactively, after they’ve left the hospital.
Thankfully, in recent years, advocates have won protections for patients that make the question of admittance versus observation more transparent. As of 2017, hospitals must use a form called a MOON (Medicare Outpatient Observation Notice) to notify all patients who are under observation for more than 24 hours what that status means and what Medicare will and will not cover. Staff must provide written and oral notice within 36 hours of the patient entering care. However, since that notice period might be longer than the observation period itself, a patient could still go home after an overnight hospital stay thinking their stay was covered when it wasn’t.
Late last year, the Center for Medicare Advocacy won additional rights for patients in a case against Medicare. The new policies require hospitals to inform patients when their status changes from admittance to observation. Even better, the new rules allow patients to appeal changes of status that caused their stay at an SNF not to be covered by Medicare. The ability to appeal applies retroactively to patients who were affected by a change of status since 2009. Looking ahead, the Medicare Rights Center and others are fighting to eliminate the three-day inpatient stay requirement for SNF care coverage.
For now, as an individual, stay aware that an outpatient stay can look just like an inpatient stay, with a very different price tag. Ask hospital staff about the status of yourself or loved one, and request a copy of their policies on changes in admission status.