Japan revises the 「定額負担」 (flat-rate payment) for visits made without a referral letter and similar cases — 紹介受診重点医療機関 added to the hospitals covered, the first-visit 医科 amount raised to 7,000 yen, and a new deduction from the scope of insurance benefits (took effect October 1, 2022)
Source material is a Japanese government announcement (in Japanese); this page is a summary.
From October 1, 2022 (令和4年10月1日), for visits made without a referral letter and similar cases to a 特定機能病院, a 地域医療支援病院 (一般病床200床以上に限る) or a 紹介受診重点医療機関 (一般病床200床以上に限る), the flat-rate payment rose to 7,000 yen for 医科 and 5,000 yen for 歯科 at a first visit and 3,000 yen for 医科 and 1,900 yen for 歯科 at a return visit, and the treatment whereby 200点 for 医科 and 歯科 at a first visit and 50点 for 医科 and 40点 for 歯科 at a return visit are deducted from the scope of insurance benefits was carried alongside it. The source, however, lists ①–⑩ for first visits as 「定額負担を求めなくても良い場合」 (cases where the flat-rate payment need not be charged) and states 「緊急その他やむを得ない事情がある場合には、定額負担を求めてはならない」 (where there are emergency or other unavoidable circumstances, the flat-rate payment must not be charged), so not having a referral letter does not always mean paying these amounts.
Key facts
| Date of entry into force and transitional measure | 「令和４年10月1日から施行・適用」 (takes effect and applies from October 1 of 令和4年). The source also states 「新たに紹介受診重点医療機関となってから６か月の経過措置を設ける」 (a transitional measure of 6 months from newly becoming a 紹介受診重点医療機関 is provided). |
|---|---|
| Hospitals covered (見直し後) | ① 特定機能病院 ② 地域医療支援病院 (一般病床200床以上に限る) ③ 紹介受診重点医療機関 (一般病床200床以上に限る) — of these, ③ was added in the 「見直し後」 column (the 「現行制度」 column lists only ① and ②). For other hospitals with 200 or more general beds, the source states 「選定療養として特別の料金を徴収することができる」 (a special fee may be collected as 選定療養). |
| Amount of the flat-rate payment (見直し後 / previously) | First visit: 医科 7,000 yen and 歯科 5,000 yen (previously 医科 5,000 yen and 歯科 3,000 yen) / return visit: 医科 3,000 yen and 歯科 1,900 yen (previously 医科 2,500 yen and 歯科 1,500 yen). The source, however, lists the 「定額負担を求めなくても良い場合」 below, which states that the medical institution need not collect the flat-rate payment — not that collecting it is prohibited. What prohibits charging it as such is the other sentence, 「緊急その他やむを得ない事情がある場合には、定額負担を求めてはならない」. |
| Deduction from the scope of insurance benefits (newly written in 見直し後) | For the first and return visits of patients who are charged the flat-rate payment (in the source's wording, 「あえて紹介状なしで受診する患者等」, patients who deliberately visit without a referral letter and the like), 200点 for 医科 and 200点 for 歯科 at a first visit, and 50点 for 医科 and 40点 for 歯科 at a return visit, are deducted from the scope of insurance benefits. The source explains this as an 「外来機能の明確化のための例外的・限定的な取扱い」 (exceptional and limited treatment for the purpose of clarifying outpatient functions), and carries alongside it an illustrative diagram of a 医科初診・選定療養費7,000円・患者負担3,000円 case. |
| Patients covered (the rule) and its exceptions | The 「現行制度」 column of the source describes the patients covered as, for a first visit, 「他の病院又は診療所からの紹介状なしで受診した患者」 (a patient who visited without a referral letter from another hospital or clinic), and for a return visit, 「他の病院（病床数200床未満に限る）又は診療所に対して、文書による紹介を行う旨の申出を行ったにもかかわらず、当該医療機関を受診した患者」 (a patient who visited the institution in question even though an offer to make a referral in writing to another hospital (limited to those with fewer than 200 beds) or clinic had been made). The note in the 「見直し後」 column likewise explains the return-visit patients covered as 「他の病院等に対して文書による紹介を行う旨の申出を行ったにもかかわらず、当該医療機関を受診した患者」, while stating that 「現行制度における①、②、③、⑥、⑦に該当する場合は想定されえないため、要件から削除」 (because cases falling under ①, ②, ③, ⑥ and ⑦ of the current system cannot be envisaged, they were deleted from the requirements). Attached to this rule are the 「定額負担を求めなくても良い場合」 below and the 「求めてはならない」 provision. |
| Cases where the flat-rate payment need not be charged (見直し後, first visits) | Visiting a covered hospital without a referral letter means the flat-rate payment as a rule, but the source lists the 「定額負担を求めなくても良い場合」 as ① 自施設の他の診療科から院内紹介されて受診する患者 ② 医科と歯科との間で院内紹介された患者 ③ 特定健康診査、がん検診等の結果により精密検査受診の指示を受けた患者 ④ 救急医療事業、周産期事業等における休日夜間受診患者 ⑤ 外来受診から継続して入院した患者 ⑥ 地域に他に当該診療科を標榜する保険医療機関がなく、当該保険医療機関が外来診療を実質的に担っているような診療科を受診する患者 ⑦ 治験協力者である患者 ⑧ 災害により被害を受けた患者 ⑨ 労働災害、公務災害、交通事故、自費診療の患者 ⑩ その他、保険医療機関が当該保険医療機関を直接受診する必要性を特に認めた患者. Attached to ⑩ is the proviso 「急を要しない時間外の受診、単なる予約受診等、患者の都合により受診する場合は認められない」 (visits outside hours that are not urgent, mere appointment visits and other visits made for the patient's own convenience are not allowed). The source also states 「緊急その他やむを得ない事情がある場合には、定額負担を求めてはならない」 (where there are emergency or other unavoidable circumstances, the flat-rate payment must not be charged) and 「正当な理由がある場合には、定額負担を求めなくても良い」 (where there is a legitimate reason, the flat-rate payment need not be charged) (both sentences appear in the 「現行制度」 column, and what was presented in 「見直し後」 as subject to revision is the list above). Whether this list covers every case in which no payment arises is not stated by the source. |
| The nature of this document | The cover states 「本資料は現時点での改定の概要をご紹介するためのものであり、必ずしも最終的な施行内容が反映されていない場合等があります。算定要件・施設基準等の詳細については、関連する告示・通知等をご確認ください」 (this document is to introduce an outline of the revision as of the present time and may not necessarily reflect the final content as enforced; for details such as the requirements for calculation and the facility standards, please check the related 告示 and 通知) (厚生労働省保険局医療課, the 令和４年３月４日 version). |
Last checked:
In the 令和4年度 revision of medical fees, Japan revised the 「紹介状なしで受診する場合等の定額負担」 (flat-rate payment for visits made without a referral letter and similar cases), which took effect and applies from 令和4年10月1日 (October 1, 2022). The source states the purpose of the revision as reworking, 「外来機能の明確化及び医療機関間の連携を推進する観点から」 (from the standpoint of clarifying outpatient functions and promoting cooperation between medical institutions), the range of medical institutions that have a duty to collect the flat-rate payment as well as the scope of insurance benefits and the amount of the flat-rate payment for treatment of the patients covered at those institutions. Under 「見直し後」 (after the revision) the hospitals covered are the three types 特定機能病院, 地域医療支援病院 (一般病床200床以上に限る, limited to those with 200 or more general beds) and 紹介受診重点医療機関 (一般病床200床以上に限る), the third of which was added this time. The flat-rate payment became 7,000 yen for 医科 (medical) and 5,000 yen for 歯科 (dental) at a first visit, and 3,000 yen for 医科 and 1,900 yen for 歯科 at a return visit (previously 5,000 yen 医科 and 3,000 yen 歯科 at a first visit, and 2,500 yen 医科 and 1,500 yen 歯科 at a return visit). Alongside this, the 「見直し後」 column also carries the treatment whereby, for the first and return visits of patients who are charged the flat-rate payment, 200点 (points) for 医科 and 200点 for 歯科 at a first visit, and 50点 for 医科 and 40点 for 歯科 at a return visit, are deducted from the scope of insurance benefits. Not having a referral letter does not always give rise to the payment, however: the source lists ①–⑩ for first visits as 「定額負担を求めなくても良い場合」 (cases where the flat-rate payment need not be charged — in-hospital referral from another department of the same institution, visits on holidays or at night under 救急医療事業 or 周産期事業 and the like, patients who suffered damage from a disaster, 労働災害, 公務災害, traffic accidents, self-paid treatment and so on), and also states 「緊急その他やむを得ない事情がある場合には、定額負担を求めてはならない」 (where there are emergency or other unavoidable circumstances, the flat-rate payment must not be charged). The document itself says 「本資料は現時点での改定の概要をご紹介するためのもの」 (this document is to introduce an outline of the revision as of the present time) and advises checking the related 告示 and 通知 for details such as the requirements for calculation and the facility standards.
Summaries below are factual notes based on government announcements and primary sources — not evaluations or opinions.
Summaries reflect national-level programs. Municipal (city/ward/town) programs may differ — confirm with the official desk before applying.
FAQ
If I go to a large hospital without a referral letter, do I always have to pay 7,000 yen?
In the source, the flat-rate payment is charged for visits to a covered hospital made without a referral letter and in similar cases, and the 「見直し後」 amounts are 7,000 yen for 医科 and 5,000 yen for 歯科 at a first visit and 3,000 yen for 医科 and 1,900 yen for 歯科 at a return visit. The source, however, lists ①–⑩ for first visits as 「定額負担を求めなくても良い場合」 (in-hospital referral from another department of the same institution, in-hospital referral between 医科 and 歯科, an instruction to undergo a detailed examination following the results of a 特定健康診査 or a cancer screening, visits on holidays or at night under 救急医療事業 or 周産期事業 and the like, cases where the patient was admitted continuously from an outpatient visit, a department for which there is no other medical institution in the area holding itself out as providing it, a 治験協力者 (clinical-trial collaborator), patients who suffered damage from a disaster, 労働災害, 公務災害, traffic accidents, self-paid treatment and so on), and it also states 「緊急その他やむを得ない事情がある場合には、定額負担を求めてはならない」. Conversely, attached to ⑩ is the proviso 「急を要しない時間外の受診、単なる予約受診等、患者の都合により受診する場合は認められない」. Whether this list is exhaustive is not stated by the source, which advises checking details such as the requirements for calculation in the related 告示 and 通知.
Which hospitals are covered?
The hospitals covered under 「見直し後」 are 特定機能病院, 地域医療支援病院 (一般病床200床以上に限る) and 紹介受診重点医療機関 (一般病床200床以上に限る). The 「一般病床200床以上に限る」 in the brackets is a limitation attached to the latter two types, and an institution that does not meet this requirement does not fall within them. For other hospitals with 200 or more general beds, it is written that 「選定療養として特別の料金を徴収することができる」. Where an institution has newly become a 紹介受診重点医療機関, a transitional measure of 6 months is provided. Even at a covered hospital, if the case falls under the 「定額負担を求めなくても良い場合」 above, the medical institution need not charge the flat-rate payment, and as for 「緊急その他やむを得ない事情がある場合」 the source states 「定額負担を求めてはならない」 (it must not be charged). The former list states that the institution need not collect the payment; it does not state that exemption is guaranteed.
Besides the increase in the amounts, is there anything else that changed?
The 「見直し後」 column also carries the 「保険給付範囲からの控除」 (deduction from the scope of insurance benefits), stating that for the first and return visits of patients who are charged the flat-rate payment, 200点 for 医科 and 200点 for 歯科 at a first visit, and 50点 for 医科 and 40点 for 歯科 at a return visit, are deducted from the scope of insurance benefits. The source explains this as an 「外来機能の明確化のための例外的・限定的な取扱い」. In the source this deduction is treatment applied to 「定額負担を求める患者」 (patients who are charged the flat-rate payment), so its premise does not hold for a visit at which the flat-rate payment was not in fact charged. For details of the actual calculation, such as the requirements for calculation and the facility standards, the source advises checking the related 告示 and 通知.