Difference between OPD and IPD [Treatment + Insurance]

When it comes to treatment at hospitals, there are two common types: In-Patient Department (IPD) and Out-Patient Department (OPD) . 

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These two categories serve different purposes and cover distinct aspects of healthcare. In this blog, we will delve into the differences between IPD and OPD, and also focus on its insurance and claims process.

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What is IPD (In-Patient Department)?

In-patient treatment refers to cases where the patient needs to stay overnight for at least 24 hours or for a longer in the hospital. IPD insurance is designed to cover medical expenses when a policyholder is admitted to a hospital for in-patient treatment or surgery. 

What does IPD insurance cover?

Here are some typical things covered in IPD insurance:

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Hospitalization costs: This includes room charges, nursing expenses, and other fees associated with staying in the hospital.

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Surgical expenses: Expenses related to surgeries, operation theater charges, surgeon's fees, and anesthesia costs.

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Diagnostic tests: Charges for diagnostic tests like X-rays, MRIs, and blood tests.

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Pre and post-hospitalization expenses: Some IPD insurance policies also cover pre and post-hospitalization expenses for a specified period after discharge.

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Medications: The cost of medicines and drugs prescribed during the hospital stay.

It is important to note that coverage will be based on your policy and always check what is covered in your policy to avoid huge expenses.

What is OPD (Out-Patient Department)?

OPD stands for "Outpatient Department," and OPD treatment refers to medical care and treatment that is provided to patients on an outpatient basis. In an OPD setting, patients visit a healthcare facility, such as a hospital, clinic, or doctor's office, to receive medical attention, consultation, diagnosis, and treatment without being admitted to the hospital as inpatients

What does OPD insurance cover?

Some of the typical things OPD insurance covers are:

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Doctor's consultation fees: The charges for visiting a physician or specialist.

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Diagnostic tests: Costs associated with various tests and screenings.

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Medications: The expense of prescribed medications.

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Dental and vision care: Coverage for dental check-ups, eye examinations, and related expenses.

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Preventive care: Costs for vaccinations, health check-ups, and wellness programs.

What are the differences between OPD and IPD

How do claims work for OPD?

OPD claims are generally reimbursement claims. Read on to know how it works:

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Service type: OPD claims are related to services provided on an outpatient basis, such as doctor's consultations, diagnostic tests, minor procedures, and medications.

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Billing process: Typically, healthcare providers or clinics will provide an invoice or bill for the services rendered during an OPD visit. This bill includes a breakdown of charges for each service, consultation, or test conducted.

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Payment: Patients or their health insurance providers are responsible for paying the bill directly to the healthcare provider. Insurance plans may cover some or all of these costs, depending on the policy and coverage.

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Reimbursement: If the patient has health insurance, they can submit the bills and receipts to their insurance company for reimbursement, subject to the terms and conditions of their policy.

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Documentation: Patients need to maintain proper documentation of OPD expenses, including bills, receipts, and medical reports, for reimbursement or future reference.

How do claims work for IPD?

There are two types of claims with IPD insurance- Cashless and reimbursement. Read on to know how it works:

Cashless IPD claim process

• Cashless IPD claims are associated with health insurance policies that offer a cashless facility at network hospitals. Network hospitals are healthcare facilities with which the insurance company has a tie-up.
• When an insured person requires inpatient treatment at a network hospital, they can inform the insurance company or third-party administrator (TPA) about the hospitalization.
• The insurance company or TPA will then provide an authorization letter to the hospital, specifying the coverage details and the maximum limit up to which they will settle the bills directly with the hospital.
• The patient does not have to pay for the covered expenses out of pocket; the insurance company settles the bills directly with the hospital, including room charges, surgical expenses, and other covered medical costs.
• The insured person may still be responsible for non-covered expenses or co-payments, depending on the terms of their insurance policy.

Reimbursement IPD Claims

• Reimbursement IPD claims are applicable when a patient receives inpatient treatment at a non-network hospital or when cashless facility is not available under the insurance policy.
• In this case, the patient or their family is required to pay for the hospitalization expenses upfront.
• After the patient is discharged, they need to collect all the relevant bills, invoices, and medical reports from the hospital, which provide a detailed breakdown of the services rendered and costs incurred.
• The insured person should then submit these documents, along with a claim form, to the insurance company or TPA within the stipulated timeframe specified in the policy.
• The insurance company will review the claim and the submitted documents to ensure they are in compliance with the policy terms and conditions.
• Once the claim is approved, the insurance company will reimburse the eligible expenses to the insured person, usually via a bank transfer or check. The reimbursement amount is subject to the policy's terms, conditions, and coverage limits.
• The insured person may be responsible for any deductibles, co-payments, or non-covered expenses, as specified in their policy.

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