Category: Medical Billing

April 11, 2024 by AMS Solutions 0 Comments

Medical billing is a sector that moves incredibly quickly, while also being highly complex. In the midst of this, recoupment requests can be a significant challenge for healthcare providers. These demands for the return of previously disbursed funds can disrupt the financial stability of practices and create administrative headaches. Understanding the triggers and implications of recoupment is essential for any medical establishment aiming to safeguard its revenues.

In this post, we’ll discuss not only the nature of these requests but also how proactive measures and the right support can help mitigate their impact. In the end, we’ll also highlight a medical billing and recoupment expert. If you’re looking to strengthen your billing processes and reduce financial risk, you’re in the right place, let’s get to it.

What Are Recoupment Requests?

Recoupment refers to the process by which insurance payers reclaim funds they’ve previously paid out, typically due to claims errors or policy violations. These requests can arise from simple clerical errors, misinterpretation of guidelines, or incorrect patient information. 

The consequences for healthcare practices can be severe, ranging from cash flow interruptions to the need for extensive administrative review and response efforts. By grasping the roots and ramifications of recoupment, providers can better prepare to address and dispute these requests when necessary.

Preventive Measures for Recoupment Requests

The best approach to handling recoupment requests is preventing them from occurring in the first place. Here are some essential strategies that may help your practice keep more of the money your practice makes. 

  1. Detailed Documentation: Maintain comprehensive and accurate patient records. Ensure that all services are properly documented with the correct codes and that these records are easy to retrieve and review.
  2. Timely Billing Practices: Submit claims promptly and ensure they are complete and accurate. Delayed or incorrect claims are more likely to be flagged for recoupment.
  3. Regular Compliance Audits: Conduct regular audits to ensure that billing practices comply with payer guidelines and regulations. This not only helps in identifying potential issues before they result in recoupment but also strengthens the overall billing process.
  4. Education and Training: Keep your billing staff updated on the latest coding standards and healthcare regulations. Continuous education helps in reducing errors that could lead to recoupment.

How AMS Solutions Can Help

Navigating the complexities of medical billing and recoupment requests requires expertise and precision, qualities that AMS Solutions embodies. With years of experience in the medical billing industry, our team is equipped to handle the challenges that come with managing recoupment requests. We offer a suite of services designed to fortify your billing processes, including advanced software, expert response, and even custom training for your staff.

Our technology ensures accurate claim submissions, reducing the chances of errors that could lead to recoupment. We provide thorough review and swift response services to manage and dispute recoupment requests effectively. AMS Solutions also offers tailored training programs to keep your staff abreast of the latest billing practices and compliance requirements.

Partner with AMS to Combat Recoupment Requests

Effectively managing recoupment requests is crucial for maintaining the financial health and operational efficiency of any healthcare practice. By implementing robust preventive measures and leveraging professional expertise, you can significantly reduce the burden of these financial setbacks.

AMS is ready to be your trusted partner in battling recoupment requests. With our advanced billing solutions, expert support, and comprehensive training, we empower your practice to handle recoupment challenges with confidence. 

Don’t let recoupment requests disrupt your service delivery and financial stability. Contact AMS Solutions today to learn more about how we can help make your billing processes more efficient, and safeguard your revenue against unnecessary losses. 

March 21, 2024 by Mike Moffit 0 Comments

Urgent care facilities operate in a fast-paced environment where efficient billing processes are crucial for financial stability and operational success. The decision to hire a billing company is significant, impacting both the financial health of the facility and the quality of patient care. 

Outsourcing billing can offer expertise and efficiency but comes with considerations like cost and control. In this post, we’ll be digging into the advantages and disadvantages of engaging a billing company for urgent care facilities, helping owners and managers make more informed decisions about their billing operations and their practice as a whole.

Pros of Hiring a Billing Company

Expertise in Urgent Care Billing and Coding

Billing companies specialize in the intricacies of medical billing and coding, particularly in the urgent care setting. Their expertise ensures that claims are accurately coded and submitted promptly, reducing the risk of denials and improving revenue flow. This specialization is critical in urgent care, where diverse treatments and rapid patient turnover require precise and efficient billing processes.

Enhanced Revenue Cycle Management

A professional billing company brings streamlined processes and sophisticated technology to manage the revenue cycle effectively. This includes tracking claims, managing accounts receivable, and ensuring timely payment. Their systems are designed to minimize errors and optimize billing operations, leading to improved cash flow and financial performance for the urgent care facility.

Focus on Patient Care and Operational Efficiency

Outsourcing billing allows urgent care providers to concentrate on their primary mission: delivering high-quality patient care. It reduces the administrative burden on healthcare professionals and staff, enabling them to focus more on patient reactions and clinical duties. 

Additionally, it can lead to better operational efficiency, as the urgent care facility can allocate resources and space that would otherwise be dedicated to an in-house billing department to other critical areas of patient care and service expansion.

Cons of Hiring a Billing Company

Potential Costs and Fees

While outsourcing billing can lead to increased revenue and efficiency, it comes with direct costs. Billing companies typically charge a percentage of the collections they process, which can be substantial depending on the volume and value of claims. 

For some urgent care facilities, especially smaller ones, these fees may be a significant consideration, impacting the overall cost-benefit analysis of outsourcing billing services.

Loss of Direct Control

Hiring a billing company means entrusting a crucial aspect of the facility’s operations to an external entity. This arrangement can lead to concerns about losing direct control over billing processes and financial management. 

Urgent care managers may feel distanced from the day-to-day handling of billing, which can affect their ability to oversee and respond quickly to billing-related issues or changes in revenue patterns.

Challenges Finding a Compatible Billing Partner

Not all billing companies are created equal, and finding one that aligns well with an urgent care facility’s specific needs and expectations can be challenging.

Issues like mismatched communication styles, differing priorities, and incompatible billing practices can arise, potentially affecting the efficiency and effectiveness of the billing process. This means urgent care facilities have to conduct thorough research and vetting to ensure that the billing company they choose is a good fit for their operational model and culture.

Partner With AMS Solutions for Urgent Care Billing Success

Choosing AMS Solutions for your urgent care billing needs means aligning with a partner dedicated to maximizing your financial performance while allowing you to focus on patient care. Our expertise in urgent care billing and coding, combined with efficient revenue cycle management, addresses the complexities of the healthcare financial landscape. Contact AMS Solutions today to discuss the needs of your practice, and we’ll tell you how we can help.

March 11, 2024 by AMS Solutions 0 Comments

Few fields move quicker than healthcare, and when it comes to primary care practices, managing the financial side of a practice can be as complex as diagnosing and treating patients. With the ever-changing landscape of healthcare regulations and insurance protocols, billing has become a significant challenge for many practices. This complexity often leads to the question: Should I hire a billing company for my primary care practice? 

In this post, we’re going to look at how hiring a billing company can streamline the financial operations of a practice. How it can help reduce the burdens of in-house billing, allowing healthcare providers to focus on patient care rather than paperwork.

The Challenges of In-House Billing

Effectively managing in-house billing for a primary care setting is loaded with challenges. First and foremost is the sheer complexity of medical billing, which requires substantial knowledge of billing codes and compliance standards and requirements. 

In-house staff must stay up-to-date with the latest billing regulations and insurance requirements, which can be a daunting task. Not only that, but the process itself is a significant drain on time and resources that could be better allocated to caring for patients and growing the practice. 

In-house billing also opens the door to potential errors, which can range from incorrect coding to missed billing opportunities, each of which has the potential to be responsible for delayed payments or outright denials from insurance companies.

In the big picture, these errors don’t just mean lost revenue, hampering the financial health of the practice, but they also require additional time to rectify, taking away even more resources from core medical activities.

Finally, the requirement to maintain compliance with healthcare laws and regulations adds an extra layer of complexity and expense, making in-house billing a risky and relatively stressful workload for most primary care practices. 

Benefits of Hiring a Billing Company

Outsourcing to a billing company offers numerous advantages for primary care practices. Firstly, it brings expertise and experience to the table, ensuring that billing is handled by specialists who are up-to-date with the latest healthcare regulations and insurance policies. This expertise lowers the chance of billing errors and compliance issues. 

Financially, hiring a billing company can be more cost-effective than managing billing in-house. It eliminates the need for extensive billing staff, costly training programs, and the investment in billing software and hardware. Billing companies will often operate on a percentage of their collections, which gives them a significant incentive to maximize the practice’s revenue.

Additionally, companies that specialize in billing already have the resources and infrastructure to manage billing processes efficiently. They can also typically scale their services to match the growth and needs of the practice. They use advanced technology and analytics to track billing patterns and identify areas for improvement, which can lead to increased revenue and more efficient practice operations.

On top of these operational benefits, outsourcing billing allows primary care providers to focus on what matters the most: caring for their patients. Lowering the administrative burden allows healthcare professionals to dedicate more resources to delivering leading medical services, and growing patient satisfaction 

Trust AMS Solutions for Top-Tier Primary Care Billing

Choosing to partner with AMS for your primary care medical billing needs means your practice will be embracing efficiency, expertise, and financial health. We bring you a proven track record of maximizing revenue while simultaneously streamlining billing processes, letting you and your staff pour your focus into the delivery of excellent patient care. Don’t let the distraction and liability of in-house billing hold back your practice, reach out to AMS Solutions today to get started.

February 2, 2024 by AMS Solutions 0 Comments

We’re in the middle of deductible season: The time of year when most insurance plans reset deductibles back to $0 and in the meantime, patients are responsible for the full contracted rate of their sessions until they have finally met their set amounts. So, what exactly does this mean to your practice?

Deductible season lasts typically the first three to five months of the year, depending on your location, medical specialty and the patient volume you support. This can be really tough on medical providers for a couple of reasons: First, without insurance payments coming in, your practice’s income can take a hit at the beginning of the year. Second, patients will be receiving higher bills than usual and not all of them will feel prepared to pay these amounts, which can become a financial burden for your business if they go overdue on their balances.

Every healthcare provider can implement targeted strategies to navigate their unique challenges and the financial landscape of the season effectively, especially when you partner with a team that knows the ins and outs of Revenue cycle management to keep your practice in good financial health through these months. 

How to avoid delayed income during this time?

Up-to-date Documentation

As a medical provider, you must ensure that all chart notes and other paperwork requested are completed and sent to insurance companies on time, typically before the end of the previous year. This proactive approach ensures steady payments at the beginning of the deductible season and help your medical billing team keep a steady revenue flow more effectively.

Eligibility Check

Always check insurance eligibility for every patient, and this includes Medicare! Look for the following items when checking eligibility and verifying benefits:

  1. Does the patient have an active policy? What is the effective date of that policy?
  2. Does the patient have a co-pay, deductible, coinsurance, or an out-of-pocket maximum?
  3. Does the service you provide require a prior authorization or a referral?
  4. Does the patient have any secondary insurance?

Payment Collection

The easiest and most effective way to minimize the impact of deductible season, is to collect payments as accurately as possible at the time of service. Unless an insurer bars you from billing a patient (such as Medicaid).

Chances of collecting payments for deductible and co-insurance that apply to your service or co-pay balances drops 62% as soon as the patient walks out the front door according to the National Association of Healthcare Access.

Remember to always remind patients (verbally, in writing, or online) of their financial responsibility. Whether it is keeping insurance updated, patient contact information updated, and a friendly reminder that most insurers require the patient to pay the provider some portion of their bill – even Medicare.

Accessible Patient Support

One efficient solution is to offer patients the option to pay balances and submit billing questions online in real time, on their terms and not be limited by business hours or staff availability. This action not only modernizes and improves the patient’s experience but increases patient collection speeds, reduces paper statements and staffing costs while improving operational efficiency.

These strategies will help your medical practice keep a better cash flow during this deductible season. If you find yourself seeking a reliable partner to navigate these challenging times, contact us today for all-inclusive medical billing solutions tailored to your practice.

December 9, 2023 by AMS Solutions 0 Comments

Healthcare is a complex and rapidly evolving field, and one of the most critical elements for any smoothly functioning medical practice is primary care billing and coding. These are the processes vital for making sure that services, treatments, and more are all billed accurately and efficiently, and have a direct impact on both revenue and patient satisfaction. AMS Solutions specializes in simplifying these intricate procedures, offering tailored services that cater to the unique needs of primary care providers. Let’s take a closer look.

What Is Primary Care Billing?

Primary care billing is a foundational, though highly complex, aspect of healthcare management, encompassing a range of services from routine check-ups to the management of chronic conditions. Unlike specialized medical billing, primary care billing deals with a broad spectrum of patient needs, requiring a diverse understanding of billing codes and insurance policies. At the heart of this process is the need for accuracy and promptness, ensuring that healthcare providers are reimbursed for their services without delay.

Effective primary care billing hinges on a deep comprehension of the latest billing guidelines and regulations. It’s not just about submitting claims; it’s about understanding the intricacies of insurance plans, patient eligibility, and the ever-evolving landscape of healthcare policies. This is where AMS Solutions shines, offering expertise and technology-driven solutions that streamline billing processes, reducing errors and enhancing overall efficiency.

Key Guidelines for Primary Care Coding

Primary care coding is a detailed and precise process that demands a thorough understanding of medical terminology and coding systems. This is where specific guidelines come into play, guiding primary care providers in accurately coding diagnoses and procedures. Making sure these codes are correctly applied is a major part of keeping reimbursement rates and compliance up to par. 

One of the key elements in primary care coding is the use of the International Classification of Diseases (ICD) codes, which must be updated regularly to reflect the latest medical findings and treatments. In addition, primary care practices must stay abreast of the Current Procedural Terminology (CPT) codes, which relate to the various medical, surgical, and diagnostic services offered. Staying informed and compliant with these coding standards is a demanding task, but it’s crucial for the financial health of any primary care practice.

Challenges in Primary Care Billing and Coding

Despite the best efforts of healthcare providers, primary care billing and coding can present several challenges. Common issues include:

  • Coding Errors: Misapplying codes is a frequent issue that can lead to claim rejections.
  • Undercoding and Overcoding: Undercoding results in lost revenue, while overcoding can trigger audits and lead to penalties.
  • Constantly Changing Regulations: Keeping up with these changes is crucial to ensure compliance and prevent legal issues. This requires ongoing training and updates, which can be resource-intensive.
  • Navigating Insurance Policies: Dealing with various insurance plans and understanding their specific policies and coverage limitations is a significant challenge.

Best Practices for Effective Billing and Coding

Adopting best practices in primary care billing and coding is essential for maintaining efficiency and accuracy. These include:

  • Regularly training staff on the latest coding updates.
  • Implementing thorough documentation practices.
  • Using advanced billing software for accuracy and efficiency.

These strategies help in minimizing errors and optimizing revenue.

Trust AMS Solutions to be Your Partner in Primary Care Billing and Coding

While the primary care billing and coding space can be complex for a small or medium-sized practice to effectively navigate, we make it simple and reliable. Our expertise ensures that your practice’s billing and coding are handled proficiently, freeing you to focus on patient care. Partner with AMS Solutions for seamless, efficient billing and coding solutions tailored to your practice’s needs. Reach out today to discuss your organization’s needs and to get started.

Two young women doctors sitting on the sofa
October 15, 2023 by AMS Solutions 0 Comments

Medical billing is a critical component in the healthcare industry, bridging the gap between healthcare providers and insurance companies. It’s a process that ensures medical professionals are compensated for their services. However, as with any rapid-evolving industry, the various complexities and nuances involved can pose challenges for many medical practices, leading to delayed or denied claims, which in turn affect the cash flow and overall financial health of the practice.

This is where medical billing companies come into play. They take up all of the administrative work needed for the billing and coding, which would normally be done by in-house staff, allowing the workforce of a healthcare provider to focus more closely on the care they provide to their patients. We’re going to look at what these medical billing companies do, how they work, and look at how outsourcing medical billing can help your business. 

What Do Medical Billing Companies Do?

Medical billing companies are one of the most effective ways to streamline a provider’s reimbursement process and shorten the billing and payment cycle. They are responsible for taking the medical services and procedures that are performed, translating them into the industry standard codes, and submitting claims for reimbursement. 

The journey of a reimbursement claim typically begins with patient visits, where coders convert the diagnoses and treatment details into universal medical codes. Following this, medical billers prepare the claims, ensuring they are error-free and compliant with insurance regulations before submitting them to the respective insurance providers.

Most medical billing companies will also follow up on submitted claims, address any denials, and ensure that the healthcare providers are reimbursed accurately and promptly. They can offer other administrative services as well, like analytics, collections, and more. 

Is It Important To Have A Medical Billing Company For My Medical Practice?

For most small and mid-sized practices, the importance of partnering with a dedicated medical billing company is hard to overstate. They serve as a buffer, ensuring that your medical practice remains financially stable and compliant with ever-evolving healthcare regulations. Medical billing companies possess the expertise to handle complex billing issues, reducing the likelihood of errors that could lead to claim denials or delays. They also free up time for your medical staff, allowing them to focus on patient care rather than administrative tasks.

Benefits of Hiring a Medical Billing Company for Your Practice

Providers that outsource their medical billing needs to a dedicated billing company can reap a range of benefits. Here are just a few of the benefits that your organization could see:

  • They have the expertise and technology to scrutinize every claim for errors
  • They stay updated on the latest coding standards and insurance policies
  • They can actionable insights into your billing processes
  • They allow your staff to focus on your patients

How AMS Solutions Leads In Effective Medical Billing

AMS Solutions is seen as a leader in the medical billing field and employs a team of dedicated and specialized professionals. Our specialists nimbly navigate the complex landscape of healthcare billing. We take the time to tailor our services to match the unique needs of each medical practice, ensuring a seamless billing process from patient visits to final reimbursements. We also lean on cutting-edge technology to ensure accuracy and compliance in every claim, significantly reducing the chances of delaying or denying your payments. 

Trusting another entity with your medical billing and coding needs is a big step for any practice, but even more so for practices that don’t have money to waste. However, partnering with AMS Solutions is a step towards financial robustness and operational efficiency for your medical practice. Let us help you elevate your practice to the next level of provider service, reach out to AMS Solutions today.

October 12, 2023 by AMS Solutions 0 Comments

The processes of medical billing and coding are critical to the healthcare industry, but there are still countless people who wonder what do medical billing and coding do. The job actually requires a substantial blend of medical knowledge, technical skills, and attention to detail, and it helps make sure that healthcare providers are paid accurately and on time for the services they render.

In this post, we’ll be taking a more in-depth look at the job of medical billing and coding, and the processes behind them. We’ll also look at some of the challenges that can pop up from time to time, and how a billing and coding administrator like AMS Solutions is prepared to help your organization scale rapidly.

Understanding The Job Of Medical Billing and Coding

To get a better idea of what medical billing and coding are, you’ll need to understand that both are distinct but closely related functions within the healthcare industry. 

Medical billing involves the process of creating billing claims from provided healthcare services and submitting these to insurance companies for reimbursement. On the other hand, medical coding is the translation of medical diagnoses, procedures, and equipment into universal medical alphanumeric codes. These codes provide a standardized language, which is essential for ensuring accurate billing and record-keeping.

The symbiotic relationship between billing and coding ensures that healthcare providers are reimbursed accurately and promptly, which in turn, supports the financial health of medical establishments. Both functions are critical in maintaining the integrity and efficiency of the healthcare financial ecosystem, easily illustrating why the field is critical.

The Process of Medical Billing

The process of medical billing is pretty meticulous. When a patient visits a healthcare provider, their demographic and insurance information is recorded. Afterward, all of the information is used to generate a bill that delineates all of the services rendered and their costs. This bill is typically then submitted to an insurance company for review and eventual payment. One of the biggest factors in the process is the intricacies, which demand a high degree of accuracy to ensure proper reimbursement.

The Process of Medical Coding

Medical coding, the counterpart to medical billing, is equally vital in the healthcare reimbursement cycle. It entails recording the various diagnoses, procedures, and treatments into codes that are universally recognized. These codes form the basis of billing and ensure that the services provided are accurately represented and reimbursed. The coding process begins with the review of medical documentation from which the relevant codes are derived and then used in the billing process. Accuracy and timeliness in coding are paramount to prevent claim denials and delays in payment.

How AMS Solutions Can Assist

AMS Solutions is one of the most trusted and proficient medical billing and coding administrators by creating a team that is well-versed in the latest coding standards, billing regulations, and insurance requirements, ensuring that your medical establishment remains compliant while optimizing revenue collections. We help alleviate the heavy administrative burden that comes along with having to keep an in-house billing and coding team up to the demands of an ever-changing industry. This way, you’ll be able to focus on what matters most, providing the care you’re known for. 

Partner With AMS Solutions For Hassle-Free Billing and Coding Administration

Understanding medical billing and coding is crucial for maintaining the financial viability of any provider. The intricate and often confusing practices involved in billing and coding are the linchpins of the entire healthcare reimbursement cycle. If you think it may be time for your organization to leave the billing and coding to the professionals and focus on your patients, reach out to AMS Solutions today. 

September 30, 2023 by AMS Solutions 0 Comments

Those who work in the medical field have a significant amount of responsibility. Not only the doctors and nurses who treat you but also the coding and billing professionals that work behind the scenes on paperwork and medical records. There are countless medical regulations and processes that go into medical coding, and it is crucial that the coding is done properly. We’re going to look at what proper coding is, and exactly what is the importance of knowing proper CPT coding.

What Is A CPT Code?

CPT stands for Current Procedural Technology, and CPT codes create a uniform reporting and coding language that is used to make reporting easier, as well as more efficient and accurate. CPT codes are used for medical billing that is either five digits, or four digits and one letter long, and they indicate medical or administrative management procedures. They are used for claims processing as well as for the creation and modification of medical care review guidelines.

Why Is Proper CPT Coding Important?

Most medical facilities rely on insurance providers for the majority of their funding and revenue. Other sources like healthcare programs contribute as well, but the greatest portion is provided by insurers. Insurance companies make their money by charging policyholders a premium, or fee, that is often paid monthly. Since there are many more people who have insurance than are sick at any one time, it allows the insurers to cover most of the medical expenses or costs for those who hold policies. That said, there is a huge portion of income coming from reimbursements, and a very tiny share coming from patients’ pockets. 


This is why proper CPT coding is so crucial. Every single patient that visits a hospital, care center, or doctor’s office has a file of medical records that need to be kept updated and accurately documented. If the coding and billing are done incorrectly, it can result in the hospital losing significant amounts of money in lost reimbursements. Additionally, accurate and correct billing and coding are needed to ensure that patients are being charged more than they should be and that their respective insurer is charged the correct portion of the costs.

Types Of CPT Codes

There are codes assigned for every potential procedure or service that medical providers can provide or perform. CPT codes even include many unlisted codes for procedures or special services that are not specified in other unique CPT codes. There are three categories of CPT codes created by the AMA, the categories are:

CPT Category I

Category I contains the largest body of standard codes. These are the codes most commonly used by healthcare providers to report frequently used services and procedures.

CPT Category II

Category II contains supplemental codes that are used for performance management and other administrative purposes. There are codes relating to patient history, diagnostics, patient safety, and follow-up procedures.

CPT Category III

CPT Category III contains the most infrequently used CPT codes. It also contains temporary codes that are used to code and bill experimental services, rare procedures, or emerging treatments. 

Understanding CPT Codes And The Importance Of Proper Coding Is Vital For Accurate Recordkeeping

Hopefully, we’ve been able to shed some light on just why proper CPT coding is so essential to the continued operation of healthcare facilities. Without accurate and proper CPT coding, patients would be charged wrong amounts for procedures they never had performed, and the facility would lose out on potentially millions in insurance reimbursements. This can jeopardize not only the health of patients but the longevity of the medical facility as well. 

September 12, 2023 by AMS Solutions 0 Comments

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.

August 19, 2023 by AMS Solutions 0 Comments

Deductible vs. out-of-pocket is a common question asked by people who are considering health insurance and even by health providers who aren’t often experienced in medical billing terms and services.

The Difference Between Deductible and Out of Pocket in Health Insurance

Out-of-pocket healthcare costs, also known as copayments or coinsurance, are a set amount of money that you’re required to pay for certain services on top of what your insurance covers. With deductibles, there are monthly payments that you make before your insurance starts to cover anything at all.

The deductible is the amount that must be paid by the insured before their insurer will start paying for medical care, and it varies depending on the type of plan chosen. An individual may have to pay up to $2,000 in medical expenses before their insurer starts paying anything at all, while a family might have to pay up to $6,000 in medical expenses before the insurer starts picking up more than 50%.

This means that those with higher deductibles can end up paying a lot out of pocket for health care, which is why many choose to have higher monthly premiums to cover that cost. Some plans may offer lower deductibles for a monthly premium increase.

Other plans with slightly higher premiums may have higher deductibles. The type of plan chosen should be based on each individual’s own needs and preferences, so it is best to consult a financial advisor before choosing a plan.

What is a Deductible?

A deductible is the amount of money that a person must pay out-of-pocket before their insurance company will start paying for a medical service. Deductibles are most common in health insurance plans, but some other types of insurance have them as well.

The purpose of a deductible is to encourage people to be more careful about how they spend their healthcare dollars. For example, if you have a $500 deductible, it will take you five months to reach the point where your insurer starts paying for your care. This means that you’ll spend less on healthcare and be more careful about what services you need and how often you use them.

What is an Out-of-Pocket Maximum?

The out-of-pocket maximum is the most you will pay for your health care services. The out-of-pocket maximum is one of the key features of a health insurance plan. The maximum out-of-pocket amount is the most a person will pay for covered medical expenses. It’s what determines how much you will have to pay for your medical services in a given year.

The out-of-pocket maximum can be different from one plan to another, but it’s usually set at a certain dollar amount. For example, the average in 2018 was $3,000 per family. Unfortunately, not everyone can afford to pay out of pocket.

Why Do Some People Pay Out of Pocket?

The Affordable Care Act (ACA) requires that all Americans have health insurance coverage. However, some people are not able to afford the monthly premiums.

Some people may not be able to afford the monthly premiums because they are living paycheck-to-paycheck and cannot justify spending money on something they don’t need like health insurance. Other people may be eligible for Medicaid but do not know how to enroll or don’t want to take advantage of any government assistance programs that are available.

While some people may be eligible for Medicaid, they will often find that the Medicaid plans have high deductibles and copays which can make it difficult for them to get the care they need when needed.

In addition, many doctors are not accepting new Medicaid patients due to low rates of reimbursement from the federal government. If you need help with figuring out insurance policies and terms for your healthcare practice, please contact us today. You can also visit our detailed FAQ at your convenience.

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