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Understand a Key Difference between Professional vs Institutional Billing

What is Professional Billing in Healthcare?

Explanation of Professional Billing

Professional billing in healthcare is the practice of billing for medical services deliver by individual healthcare providers, such as physicians, specialists, or other practitioners. It involves creating claims for services provided to patients and presenting them to insurance companies or patients for payment.

A female doctor in a lab coat pointing towords the professional billing vs institutional.

Role of Medical Billers in Professional Billing

Medical billers play an essential role in professional billing because they translate medical services into codes, properly appropriate billing, and follow up on claims to ensure payment. They connect closely with healthcare providers to understand the services delivered and to ensure that claims are completed appropriately and timely.

Submit claims in professional billing

In professional billing, claims are often submitted using by the CMS-1500 form, which includes information about the services delivered, the patient, and the insurance coverage. Medical billers validate information, check for errors, and submit claims electronically or by mail to the payers.

What is institutional billing, and how does it differ?

Overview of Institutional Billing

Institutional billing, on the other hand, is the billing of medical services performed by hospitals, clinics, or other healthcare facilities. It consists of inpatient and outpatient care and covers a wider range of services than professional billing.

Difference in Professional and Institutional Billing

The primary difference between professional and institutional billing is the type of services supplied and the entities that deliver those services. Professional billing focuses on individual healthcare practitioners, while institutional billing includes services offered by healthcare facilities.

Payment Process for Institutional Billing

Institutional billing is a more complex payment process because of the range of services provided and the involvement of various departments within a healthcare institution. In institutional billing, payment might come from insurance payments, government programs, and patient personal expenses.

How Does the Revenue Cycle Differ Between Professional and Institutional Billing?

Understand the Revenue Cycle in Professional Billing

The revenue cycle in professional billing describes the process of capturing, billing, and collecting money for the services performed by individual healthcare providers. It includes confirming patient insurance, accurately coding services, and following up on claims to ensure timely payment.

Revenue Cycle Management for Institutional Billing

Revenue cycle management in institutional billing is more complex, requiring collaboration among several departments, such as billing, coding, and finance, to ensure correct billing, timely payments, and compliance with regulations.

Challenges in the Revenue Cycle of Healthcare Billing

Both professional and institutional billing come across revenue cycle management difficulties such as claim denials, coding errors, and payment delays. Efficient revenue cycle management is critical for optimizing cash flow and maintaining the financial health of healthcare providers.

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What are the important components of medical billing and coding for each type?

Medical Billing and Coding for Professional Billing

Medical billing and coding involve translating healthcare services into common codes for billing purposes. Accurate coding is critical to avoiding claim denials and achieving maximum payment for services delivered.

Medical Coding in Institutional Billing

In contrast to institutional billing, medical billing, and coding cover a wide range of healthcare facility services. Coders must be knowledgeable about advanced coding systems like ICD-10 and CPT to bill appropriately for different services.

Importance of Correct Coding in Medical Billing

Accurate coding is important in professional and institutional billing to ensure that healthcare services are properly billed, claims are handled efficiently, and payment is timely. Proper coding is also useful for data analysis and tracking healthcare trends.

How Do Insurance Companies Handle Claims for Professional vs Institutional Billing?

  • Insurance Claims Process in Professional Billing

    Insurance companies handle professional billing claims by reviewing the services performed, validating the patient's coverage, and processing payment claims according to agreed-upon pricing schedules and contracts with healthcare providers.

  • Insurance Claim Process for Institutional Billing

    In institutional billing, insurance companies evaluate claims for multiple services supplied by healthcare facilities. They identify the medical necessity of services, verify coverage, and cover healthcare providers using contracted rates and contracts.

  • Payment Policies for Insurance Companies

    Insurance companies have payment policies for both professional and institutional billing that specify claim approval criteria, payment processing timetables, and settlement methods. Understanding these policies is necessary for healthcare professionals seeking quick reimbursement.

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Your Success Is Our Success

We are a team of national medical billing service experts based in Astoria, NY, committed to providing ongoing value to our customers. We leverage technology and implement best practices to provide high-quality and cost-efficient medical billing solutions from domestic locations, enabling customers to achieve their business goals. Cures Medical Billing is the best option for any medical billing needs.

Medical billing around Astoria, NY, and beyond is our core competency and our specialists will efficiently manage all your billing needs. Our medical billing specialists have over 12 Plus years of experience with all security technologies to ensure data integrity for our customers. Using our medical billing service, anyone can make their medical billing task less resource-consuming.

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Health services billing effortlessly with Cures MB. Our skilled professionals are dedicated to ensuring financial success through transparent and secure practices. Trust Cures MB for precise and careful handling of all your billing needs.

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