Professional Claims vs. Facility Claims

Are you looking to get into the medical billing career field? Then it’s important that you know what that job will entail based on the type of facility you’re working for. There are clear differences between billing between healthcare and other industries within the medical field. The processing of medical claims across varying facility types and specialties is significantly different. No matter what, medical billers work with one of two types of billing: institutional billing or professional billing. We’re going to look more closely at the differences between facility vs professional claims.

What is Professional Billing?

The staff in a doctor’s office handles many different tasks, from greeting patients and getting them checked in, to scheduling appointments and collecting money. Medical billing is also handled within the office as well. The claims that are generated for the work done by suppliers, physicians, and other non-institutional providers are considered professional billing.

These professional charges are billed on the standard CMS-1500, which is a red ink on white paper claim form that both suppliers and physicians use for claim billing. Not all claims are billed on paper. Most insurance companies, including Medicare and Medicaid, primarily accept electronic claims. When the claims are submitted electronically, it’s the 837-P rather than a CMS-1500.

What is Institutional Billing?

Institutional billing is the billing of claims for work done by institutions. Healthcare facilities like hospitals, nursing homes, and similar facilities that offer inpatient and outpatient services use institutional billing. Not only will it include services performed by the facility, but also the use of various pieces of equipment, the use of laboratory services, radiological imaging services or equipment, and more.

Biggest Differences Between Billing Types

When you compare the basics, it may seem like there isn’t much difference between professional and institutional billing. However, there are some key ways they are separated. The biggest differences between a facility claim vs a professional claim are the duties available as well as the types of forms used. 

Different Forms

Professional billing claims are billed using a CMS-1500 form. The CMS-1500 is a standard form that has red ink on white paper. It is used not just for physicians, but for supplier claim billing as well. If the billing is done electronically, the digital version of the CMS-1500 is the 837-P, with the P standing for professional claims.

Institutional claims are billed using a form called a UB-04. The paper version of this form is also red ink on white paper and is used for the physical billing of institutional charges. The electronic version of the UB-04 is the 837-I, with the I standing for institutional claims.

Roles Addressed

When looking at professional vs facility billing, there are unique claims for different industries and jobs. Facility claims deal with hospital and laboratory services, while professional claims are for physicians that work in medical offices.

Duties and Skills

Regardless of the type of billing, professional vs. facility, medical billing professionals have a crucial responsibility. Medical billers must learn about five distinct areas of billing, including:

1. Understanding how to obtain or use information about each insurance company to submit claims efficiently.
2. Knowing how to perform their duties while maintaining medical confidentiality and avoiding HIPAA violations.
3. Having a working familiarity with the specific billing software that is used will result in massive time savings for training, will reduce errors, and prevent issues and headaches in general.
4. Understanding that coordination of benefits information is vital and that submitting claims in the proper order reduces delays in payment.
5. Understanding that each portion of a medical claim is representative of information collected during the entire time from patient scheduling through treatment.