Clinic or Hospital? The ¥7,000 Mistake Foreigners Make

Going to a large hospital without a referral costs ¥7,000+ extra and a 2-4 hour wait. Japan's two-tier system explained: when to use a clinic, when you need a hospital, and how the referral letter works.

Bottom line: Going straight to a large hospital in Japan without a referral costs you an extra ¥7,000+ on top of your normal copay — and you'll wait 2–4 hours. Clinics handle 90% of what foreigners need (colds, fevers, injuries, prescriptions) faster and cheaper. This guide explains Japan's two-tier system and gives you a simple decision framework.

Information current as of March 2026 based on MHLW guidelines and hospital fee schedules. As the founder of LO-PAL and a former Medical Coordinator for Foreign Patients at a hospital in Osaka, I personally guided dozens of patients who came to the wrong facility — and watched them pay extra or wait hours unnecessarily. Understanding this system saves you time and money every single time you need care.

The two-tier system: clinics and hospitals

Japan intentionally separates first-line care (clinics) from specialist care (hospitals). This is fundamentally different from many countries where "hospital" is the default for everything.

	Clinic (クリニック / 診療所 / 医院)	Hospital (病院)
Beds	Under 20 (most have 0 — outpatient only)	20 or more
What they treat	Everyday issues: colds, allergies, minor injuries, chronic conditions, prescriptions, basic tests	Complex cases: surgery, inpatient care, specialist diagnosis, emergencies
How to visit	Walk in or call for appointment	Referral letter (紹介状) recommended for large hospitals
Cost	¥2,000–5,000 per visit (30% copay)	Same base copay + ¥7,000+ extra without referral at 200+ bed hospitals
Wait time	15–60 minutes typical	1–4 hours common
Hours	Usually Mon–Sat, closed evenings/Sundays (varies)	Outpatient: weekdays only. ER: 24/7

The ¥7,000 penalty: 選定療養費 explained

When you visit a hospital with 200 or more beds without a referral letter (紹介状), you're charged a 選定療養費 (sentei ryōyōhi) — a "facility selection fee" — on top of your normal insurance copay. This fee is not covered by insurance.

Hospital size	Extra fee without referral (initial visit)	Extra fee without referral (return visit)
200+ beds (general)	¥7,000+ (varies by hospital)	¥3,000+ (if referred back to clinic but you return to hospital)
Under 200 beds	No extra fee	No extra fee
University hospitals / large medical centers	Often ¥7,700–¥11,000	¥3,300–¥5,500

This fee was introduced to encourage people to use clinics for first-line care and reduce overcrowding at hospitals. It applies to everyone, not just foreigners.

When the fee does NOT apply:

You have a referral letter (紹介状) from another doctor
It's a genuine emergency and you arrived by ambulance
You're a follow-up patient at that hospital (already under treatment there)
The hospital has fewer than 200 beds

Decision flowchart: clinic or hospital?

Go to a CLINIC if:

You have a cold, fever, sore throat, cough
You need a prescription refill or new prescription
You have a minor injury (cut, sprain, bruise)
You need a routine checkup or blood test
You have an ongoing chronic condition (diabetes, hypertension, etc.)
You need a specific specialist (dermatologist, ENT, orthopedist) — many specialists run their own clinics
You need a referral letter to see a hospital specialist

Go to a HOSPITAL if:

A clinic doctor gave you a referral letter (紹介状)
You need surgery, inpatient treatment, or complex tests (MRI, CT, endoscopy)
It's a genuine emergency (call 119 first)
You're already under treatment at that hospital

After-hours (evening/night/weekend)?

Non-emergency: Check if your city has a designated night clinic (夜間急病診療所). See our urgent care guide
Emergency: Call 119
Not sure if it's an emergency? Call the #7119 health consultation hotline (available in some prefectures) for advice on whether to call an ambulance

How the referral letter (紹介状) works

Visit a clinic first. Explain your symptoms. The doctor examines you.
If you need a specialist or hospital care, ask: 「紹介状をお願いできますか？」(Shōkaijō o onegai dekimasu ka?)
The doctor writes a referral letter to a specific hospital/department. Cost: ~¥750 (your 30% of ¥2,500).
Call the hospital to make an appointment with the referral letter. Some hospitals accept walk-ins with a letter, but calling is better.
At the hospital, hand over the referral letter at reception. No extra fee charged.

Can you request a referral to a specific hospital? Yes. Tell your clinic doctor which hospital you'd like to be referred to. They'll typically accommodate your preference.

Specialist clinics: the shortcut foreigners miss

Here's what catches many foreigners off guard: in Japan, specialists run their own clinics. You don't necessarily need to go to a hospital to see a dermatologist, orthopedist, ENT specialist, ophthalmologist, or even a psychiatrist.

Examples:

Skin problem? Search for 皮膚科 (hifuka) + your area. Walk in, no referral needed.
Ear/nose/throat? Search for 耳鼻咽喉科 (jibi inkōka) + your area.
Eye problem? Search for 眼科 (ganka) + your area.
Bone/joint/muscle? Search for 整形外科 (seikei geka) + your area.
Mental health? Search for 心療内科 (shinryō naika) or 精神科 (seishin-ka) + your area.

These specialist clinics charge no extra fee (no 選定療養費) and have much shorter wait times than hospital outpatient departments. Use Google Maps to find them near you — search the Japanese specialty name + your neighborhood.

Common mistakes foreigners make

Mistake	What happens	What to do instead
Going to a large hospital for a cold	¥7,000+ extra fee, 2–4 hour wait, told to go to a clinic	Go to a clinic first
Clinic-hopping without a referral	Pay initial visit fee at each clinic (¥2,000–3,000 each), no coordination between doctors	Pick one clinic, get a referral if specialist is needed
Going to a hospital ER for non-emergencies	Long wait, higher fees (night/weekend surcharges), potentially turned away	Use night clinic or wait for morning
Not getting a referral letter when referred back to clinic	Returning to the hospital later costs you the extra fee again	If the hospital doctor says "go back to your clinic," ask for a reverse referral letter (逆紹介状)

Useful Japanese for navigating the system

English	Japanese	Romaji
I'd like a referral letter	紹介状をお願いします	Shōkaijō o onegai shimasu
How long is the wait?	待ち時間はどれくらいですか？	Machi jikan wa dore kurai desu ka?
Is this a clinic or a hospital?	ここはクリニックですか？病院ですか？	Koko wa kurinikku desu ka? Byōin desu ka?
Do I need a referral?	紹介状は必要ですか？	Shōkaijō wa hitsuyō desu ka?
Is there an extra fee without a referral?	紹介状なしだと選定療養費がかかりますか？	Shōkaijō nashi da to sentei ryōyōhi ga kakarimasu ka?
I'd like to see a dermatologist	皮膚科を受診したいです	Hifuka o jushin shitai desu

Not sure where to go? Post your question on LO-PAL for free — describe your symptoms and a local helper can recommend the right type of facility, confirm they take your insurance, and even accompany you.