A Complete Guide to Professional vs. Institutional Claims in Healthcare

Touseef Riaz

September 20, 2022

professional vs. institutional claims in healthcare

Medical professionals and institutions can both make claims on your behalf. What’s the difference between professional vs. institutional claims, and why is it important to understand them? In this post, we’ll explore the difference between professional and institutional claims and explain why they are important for healthcare providers. We’ll also provide tips on making the right claim for you and answer some common questions about these claims.

professional vs. institutional claims in healthcare ucb

Professional vs. institutional claims:

  1. What are the claims?

Claims are statements that are requested for reimbursement to your insurance provider. These are usually made by a healthcare provider and are electronic submission to the insurance provider. The process of submitting claims is called billing. So, this can be made for medical services provided to patients, such as physician visits or hospital stays. Additionally, they can be created for services like dentistry or vision care. If you have health insurance, there are several types of claims that may be filed on your behalf:

  1. Inpatient claims

These claims are filed when you receive hospital services while staying overnight in a facility licensed by Medicare or Medicaid.

  1. Outpatient claims

These claims are filed when you receive a visit at an ambulatory surgery center, imaging center, or other outpatient facilities.

  1. Emergency room (ER) claims 

These claims are filed when you receive treatment in an emergency department without being admitted or transferred to another facility. ER visits may be covered under your health plan’s emergency care coverage if they meet certain criteria (e.g., you must have been referred by another physician).

  1. Professional claims: 

Professional claims are medical bills that healthcare providers submit on behalf of patients to receive payment from insurance companies or private insurers. These bills may include charges for services such as diagnosis, treatment, and prescription drugs.

Different Types of Professional Claims:

Since we are studying professional vs. institutional claims, so below are the types of professional claims include: 

  • Physician services: A physician can be any doctor or medical professional who diagnoses and treats illness or injury. This includes general practitioners, internists, surgeons, pediatricians and psychiatrists, and other specialties such as cardiologists and dentists.
  • Hospital services: Hospitals offer treatment for patients who need medical care beyond what their physician can provide at home or in an office. Additionally, these hospitals offer every type of medical service, from routine exams to urgent surgery.
  • Pharmaceutical services: Pharmaceutical companies develop medication for treating ailments like high blood pressure or diabetes. Additionally, these medications are sold through pharmacies across the country, where pharmacists dispense them to patients who need them as directed by their doctor’s prescriptions. 

The Professional Claim Submission Process:

This submission process allows healthcare providers to submit claims for services they have provided. So, this process is designed to make the claim processing smoother and easier for the provider and the insurance company. To begin the claim submission process, healthcare providers must create a secure account with the selected insurance company. It will allow them to upload their patient records to their relevant site easily. Moreover, you can also submit any documentation or quotes they may have. After this, they can begin submitting claims online. 

In other words, this professional claim submission process is relatively easy to follow and requires very little time commitment on behalf of the healthcare provider. Once everything is uploaded and processed, it usually takes around two weeks for the claim to be fully processed and approved by the insurance company. However, if you consider the professional vs. institutional claims, you might also find a little difference in its process. 

Professional Claim Submissions:

Professional claim submissions are those submitted on behalf of an individual, by an individual health care practitioner (PHC), or by a PHC organization. These submissions are meant to be filed with the insurance company to receive reimbursement for expenses incurred due to a covered injury or illness.

Why Do Professional Claims Are Complex?

These are a type of claims with a higher level of complexity than the average insurance claim. In contrast to that, there is a difference between institutional vs. professional claims. This can include:

  • Claims that require expert knowledge to evaluate and adjudicate.
  • Claims that require the involvement of multiple specialists.
  • Claims where there is uncertainty about the appropriate course of action, such as how to treat a patient or whether to perform surgery.
  • Hence, these claims can also be more time-consuming for your staff because they often involve multiple people in different departments working together on a complex case.

Benefits of Submitting a Professional Claim: 

The benefits of submitting a professional claim are manifold. Hence, the professionals will help you make a professional claim form for your need. These include:

  •  Reduced time to resolution
  •  Enhanced credibility and trustworthiness
  •  Increased chance of receiving the correct payment
  •  Improved customer service
  •  Higher accuracy in settling disputes
  •  More efficient use of resources

What is the Purpose of These Claims?

The purpose of professional claim submission claims in healthcare is to speed up the process and provide a more reliable and accurate system for processing claims. Since the current process can be time-consuming and often results in errors, it may delay or prevent patients from receiving the necessary care. Hence, by using professional claim submission claims, hospitals can reduce the time it takes to submit a claim and ensure that all the necessary information is included. This will also help avoid potential delays or disputes, leading to further patient complications that would occur in facility claims vs. professional claims. 

What are institutional claims?

Institutional claims are similar to professional claims but are submitted on behalf of a healthcare institution, such as a hospital or doctor’s office. These bills typically cover the costs of care provided to patients by the institution, such as surgeries or outpatient treatments.

Types of institutional claims:

These are different types of institutional claims:

  • Outpatient – These are claims submitted by physicians who treat patients at their office or clinic. The most common type of outpatient claim is for a visit with a physician. Still, they can also include visits to mental health professionals and other healthcare providers like dentists or eye doctors.
  • Inpatient – These are hospital claims when a patient is brought in for treatment. Moreover, these claims may include tests, procedures, surgeries, and more, as well as room charges for overnight stays in hospital wings or intensive care units (ICUs).
  • Other third-party payers (TOPS) – Third-party payers that do not fit into any other category. For instance, workers’ compensation or disability insurance companies often reimburse healthcare providers for care provided to their members or policyholders.
  • Employer self-funded plans – Employer self-funded health plans typically reimburse healthcare providers for care provided to their employees and their families.

The institutional Claim Submission Process:

This claim submission process is designed to ensure that your claims are processed promptly and efficiently. So, this is another major difference when we consider professional vs. institutional claims. When you submit a claim through the submission process, it will be transferred to an insurance company or health plan responsible for processing and adjudicating the claim. So, the insurance company or health plan will contact you directly to provide information about your claim and explain the steps they will take to resolve it.

Benefits of the institutional claim submission process:

The main advantages of using the institutional claim submission process are as follows: 

-It ensures that your claims are processed promptly and efficiently. 

-You are completely in charge of who has access to your personal information, making it less likely that your claims will be mishandled or denied.

How do institutional claims are helpful? 

Institutional claims are insurance policies that cover medical expenses that are not covered by physician care. They’re typically used in healthcare settings like hospitals, pharmacies, and clinics. The biggest benefit of these claims is that they help limit the amount patients have to pay out-of-pocket for their medical expenses. Moreover, this is because most of these expenses are not protected by common insurance packages.

Another benefit of institutional claims is that they help ensure patients’ timely treatment. If a patient’s medical condition changes suddenly, they may be unable to afford the additional costs of getting prompt treatment. By having access to an institutional claim, however, the hospital can cover these costs without worrying about collecting anything from the patient. Overall, institutional claims are helpful in healthcare because they make it easier for patients to access affordable and timely medical care. 

How do professional claims differ from institutional ones? 

Professional claims are brought on patients’ behalf by physicians and other healthcare professionals. On the other hand, consider health care providers making institutional claims on behalf of a larger group—for instance, an insurance company or the government.

Frequently Asked Questions (FAQs)

  1. What are professional claims?

Professional claims are the claims that health care providers make. These providers include physicians and hospitals. Moreover, the main purpose of this type of claim is to get paid for services that have been rendered. 

  1. What are institutional claims?

Institutional claims are the claims that are submitted to an insurance company by physicians and hospitals. These are billed to patients and their insurance companies regularly. Institutional claims can be either outpatient or inpatient, depending on the patient’s treatment.

  1. How do professional claims work?

In professional vs institutional claims, the professional claims help healthcare professionals receive money for their losses as soon as possible. This is important because it allows them to cover their expenses while they’re still working and pay their mortgage or other bills. In addition, these claims can also provide financial assistance for things like vacation time, maternity leave, and relocation costs.


Ultimately, it will be up to you to determine what level of healthcare best suits your needs. I have tried my best to tell you the difference between professional vs. institutional claims. So, the main difference is that significant medical expenses should be covered by insurance coverage. In contrast, professional ones can be taken care of using a health savings account (HSA) or high-deductible plan (HDHP).

It’s time to organize your financial situation! Have you ever made changes after reading about what we wrote above? 

You May Also Like…


Submit a Comment

Your email address will not be published. Required fields are marked *

Ready To Get Started?

Pin It on Pinterest