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Professional vs Institutional Claims: What’s the Difference?

Institutions and professionals can both make claims on a patient’s behalf.
So, what exactly do professional vs institutional claims entail?

Why is it important to understand the difference between institutional vs professional claims?

For the purpose of this guide, we will explore both of these approaches to medical billing services (institutional and professional claims). We will also explain why both of these are essential for healthcare providers.

Professional vs Institutional Claims

The significant distinction between institutional claims vs professional claims is that hospital or institutional claims center on billing methods instead of medical coding. However, professional billing, on the other hand, focuses on and involves medical coding.
Allow us to elaborate more on professional vs institutional claims:

1. Professional Medical Billing

Professional billing is responsible for charging for medical services or treatments given by healthcare professionals or physicians to patients with medical coverage. For the same reason, professional medical billing is known as physician billing. The medical office covers the administrative responsibilities of medical practice, including:

  • Patient visits
  • Arranging consultations
  • Registration and verifications
  • Money collections
  • And other services, including medical billing.

All in all, professional billing is a necessary procedure that governs many administrative duties concerning healthcare practices, and these include:

  • Appointment scheduling
  • Front office greeting patients
  • Payment processing
  • Registration and verifications

Credible proof for these is essential as exceptionally specific in-patient and out-patient treatments are invoiced under the patient’s insurance plan.

2. Institutional Claims

Institutional claims entail the process of invoicing in-patient and out-patient services offered by healthcare organizations such as hospitals; the process is known as institutional billing. Furthermore, hospital billing is also mostly referred to as institutional billing.
Further, the institutional claims account centers on professional nursing services. In addition to that, institutional claims also account for services including:

  • Laboratory testing
  • Health products
  • Equipment
  • Radiology, and more.

Biller Responsibilities for Professional vs Institutional Claims

Institutional billers have duties that are highly contrasting to those of professional billers. Most institutional billers are solely responsible for billing processing or even handle the entire billing and collection processes. The essential duties of the institutional billers include:

  • Payment collection
  • Charging
  • Medical billing

Characteristics of Professional vs Institutional Claims and Billing

Medical billers, for either professional claims vs institutional claims, have a vital role in the healthcare processing and industry. All billers need to stay aware of the following important areas:

  • Healthcare experts must have access to the vast volumes of data for an insurance company to submit successful medical claims
  • Medical billers with access to confidential or internal patient data must be familiar with HIPAA privacy and security regulations.
  • Having field knowledge and expertise can save billers a lot of time, lower errors, and even remove procedural difficulties.
  • Understanding how to charge medical claims to avoid payment delays precisely

Duties and Skills of Professional and Institutional Billers

Irrespective of the type of billing, the medical billing professionals have an essential responsibility. Healthcare billers must learn about the five important and distinct areas of billing, and these include the following:

  • Learning how to get and utilize the information for each insurance company for the submission of claims efficiently
  • Maintaining medical confidentiality while performing duties and effectively avoiding HIPAA violations.
  • Knowing the working of specific billing software or tools results in massive cuts in training times, reduces errors, and prevents issues, plus any general headaches.
  • Acknowledging that coordination of benefits information is important and adequately ordered claims submissions reduce payment delays.
  • Knowing that every portion of the medical claim represents data collected from the time of patient scheduling and through the treatment.

Final Word - Professional vs Institutional Claims Increasing Revenue

The professional and institutional billing and claims are distinct regarding revenue distribution or the rising revenue reimbursements. Nevertheless, professional vs institutional claims processing plays a vital role in preventing fraudulent actions and claim denials. It is the primary responsibility of the billers to ensure no claims, whether professional or institutional, go unnoticed. Furthermore, the biller must also be aware of the medical billing and coding problems that might present.

Frequently Asked Questions

The most significant difference between professional and institutional billing is that professional billing limits the services from a physician or a team of physicians. On the other hand, institutional claims and billing cover all administrative and intervention charges for a patient’s stay in a hospital.
Professional billing includes both in-patient and out-patient services provided by a physician. These services are billed after verification and fall under the patient’s insurance plans.
ICD stands for International Classification of Diseases. It promotes international comparability in the collection, classification, processing, and presentation of stats.



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