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Outpatient visits to large hospitals without a referral mean higher co-pays


Did you know that if you visit an outpatient clinic of a large hospital without a referral, you will be charged a “special fee” in addition to the consultation fee?
Until now, special fees of 5,000 yen (3,000 yen for dentistry) or more for an initial visit and 2,500 yen (1,500 yen for dentistry) or more for a follow-up visit were added to the
consultation fee. That “special fee to be paid when visiting a major hospital without a letter of referral” will be even higher starting October 2022.

How much will the special fee without a letter of referral be?

When a patient visits an outpatient clinic of a major hospital without a letter of referral, the following fees have been charged in addition to the consultation fee.
Initial visit: ¥5,000 for medical and ¥3,000 for dental
Re-examination: ¥2,500 (medical), ¥1,500 (dental)
Since health insurance does not cover this special fee, the patient is responsible for the full amount.
This amount will be further increased as follows starting October 1, 2022.
Initial visit: 7,000 yen for medical and 5,000 yen for dental
Re-examination: ¥3,000 for medical and ¥1,900 for dental

No increase in hospital revenue

As mentioned above, in conjunction with the increase in the special fee that hospitals must charge for outpatient visits to major hospitals without a referral, a new, specific amount is
now deducted from the insurance benefit coverage.
For example, if a patient makes an initial visit to a major hospital without a letter of referral, the special fee (7,000 yen or more as of October) will have to be paid by the patient with the consultation fee. However, the consultation fee will be covered by insurance. This means that the insurance will pay for the covered items. For example, if the patient is on the 30%
self-pay program, 70% of the consultation fee is paid by medical insurance.
But if you attempt to visit an outpatient clinic at a major hospital without a referral, the logic behind this is that since you don’t mind paying the extra fee, there is only a small amount for public insurance to cover, so it will also exclude a portion of the consultation fee from the scope of public insurance benefits.
Specifically, 200 points (2,000 yen) for both medical and dental fees for an initial visit, 50 points (500 yen) for medical fees, and 40 points (400 yen) for dental fees for a follow-up visit will be excluded from insurance benefit coverage. The 2,000 yen for the initial visit, the 500 yen for the medical, and 400 yen for the dental services for the follow-up visit are just the same as the increase in the special fee that is to be paid in full.
In other words, the amount removed from insurance benefits is directly added to the patient’s co-payment. The patient’s burden will increase, but the hospital’s revenue will not increase.

What are the “big hospitals” that charge more without a referral letter?

The review also broadened the scope of “large hospitals” where co-payments are higher without a letter of referral.
Previously, the hospitals covered by the new system were hospitals with specific functions (university hospitals, cancer centers, etc.) and community hospitals with 200 or more general beds
In addition, “medical institutions that focus on receiving referrals (limited to those with 200 or more general hospital beds)” have been added to the list. Under this newly introduced framework, hospitals and clinics are designated in the region as medical institutions that provide outpatient services to referred patients.
These hospitals must charge at least 7,000 yen for an initial visit and 3,000 yen for a follow-up visit for outpatients without a referral.

Why is it so expensive without a letter of referral?

Except in special cases such as emergencies, an outpatient visit to a large hospital without a letter of referral is quite expensive, so why does the government have this system in place?
The reason for this is to define the medical care functions: large hospitals handle patients who need advanced medical care or are seriously ill, while clinics handle routine illnesses and injuries.
If a large number of patients flood the outpatient clinics of large hospitals, despite their common illnesses, the clinics will not be able to treat patients with serious illnesses, who should be treated by large hospitals. If that is the case, local medical care will not function properly.
Therefore, it is important to find a reliable family doctor at a nearby clinic or small or medium-sized hospital (hospital with less than 200 general beds) for the sake of efficient medical care, to protect local medical services, and to spare your own wallet.
◎Ministry of Health, Labour and Welfare, “Outline of Revision of Medical Service Fee in
FY2022 Outpatient I

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