What Is A Professional Claim? A Detail Guide

Touseef Riaz

June 16, 2022

outsource professional billing

If you are the one who wants to dive into the sea of medical billing and coding, then knowing the fundamentals of the area is essential. Each medical biller and coder should understand the duties and goals of their assigned position. 

Every medical biller has different duties, and everyone has to do their job effectively to make successful claims. The medical billing field has seen many challenges after the emergence of Covid-19. Due to the massive influx of patients, there were many claim denials and medical errors

There are two types of medical billing within the healthcare industry: Professional and institutional. Both of them have varied tasks to follow. The basics of both are different. 

Do you know what is a professional claim? This guide will tell you in-depth about professional claims and the things to consider under this claim. 

what is a professional claim

Professional Billing Fundamentals

Let’s explore what is a professional claim and its fundamentals.

  • Professional claims or professional billing are the billing claims generated by doctors or physicians to receive payments for their services to the patients with healthcare insurance. 
  • The form that is used for professional billing claims is CMS-1500 or 838-P. The difference between the two is that one is a paper version and the other is electronic; the rest is identical.  
  • Mainly healthcare insurance companies only accept electronic forms for reimbursing the healthcare providers. You can convert the paper version of the professional claim into the electronic version. A person expert in Professional billing claims has to be skillful in dealing with insurance companies to avoid denials. 
  • Professional billers have to take care of multiple tasks like scheduling patients’ appointments, dealing with them effectively, checking in and registering, and collecting payments. Ensure that every step is undertaken to make the whole process fluent and smooth. 
  • The billing includes both in-patient and outpatient services that can be reimbursed after patients’ insurance is verified. Without the proper verification, professional claims can’t be processed. 
  • It must be ensured that verification is done properly because there are selective services that medical insurance companies can reimburse. 
  • Medical coding is also part of professional billing, and medical billers should keep themselves updated with the new medical codes in the industry. 
  • Medical billers have to know both medical billing and coding. However, there are teams in the house that can perform these tasks but still, if medical billers have diverse knowledge, claims denials can be minimized. 

The Fundamentals of Institutional Billing

Professional Billing and Institutional Billing have their fundamentals. Let’s explore hospital billing ins and outs. 

  • The main motive of institutional or hospital billing is to generate claims from insurance companies for in and outpatient services rendered by hospitals.
  • Hospital billing also includes the bill of services rendered by nurses, laboratory services, medical equipment, etc. 
  • UB-04 or 837-I is the form that is used for hospital billing claims. One of them is paperwork, and the other is an electronic form. 
  • Professional billing claims have to deal with medical billing and coding, while hospital billing only deals with the medical billing process. 
  • Institutional Billing is much more complicated in comparison with professional billing. 

Essential Things to Know Under these Billing Claims Types?

  • The professional and institutional billing claims are diverse from each other, yet their successful compilation plays a huge role in successful reimbursements.
  • It is the core responsibility of both billers to check whether all services rendered have been billed or not. Afterward, check the code’s accuracy. Errors can be caused due to multiple reasons, and the most significant of them is medical coding errors.
  • Many hospitals and physicians outsource professional billing and institutional billing services from renowned medical billing and coding companies. 
  • The tasks included in hospital billing are way more complex than professional billing. Professionals dealing with institutional billing have to be aware of these complexities.

Outsource Professional Billing and Institutional Billing from Ucontrol Billing 

Ucontrol billing is among the best medical billing and coding companies in the US. Our main motive is to enhance your revenue cycle management process by maximizing your reimbursement rates and reducing extra expenses. 

Professional and institutional billing is not easy to handle, especially under the extreme challenges in the healthcare industry. Mainly, due to the massive influx of patients, medical billers and coders commit mistakes certainty or uncertainty that result in claim denials and your revenue loss. 

What can be done in this situation? You can count on us. We handle both hospital and professional billing in a way that pays you off positively. Ucontrol billing team members have years of experience in the healthcare industry. They are capable of handling any billing or coding task successfully. 

Here are the reasons why you should outsource services from us: 

  • We are HIPAA compliant. 
  • Patients’ information is kept 100 percent confidential. 
  • Helping collection agencies to recover patient balances. 
  • Providing cost-efficient prices for our services. 
  • Reducing your expenses. 
  • Billing in 24 hours and timely follow-ups. 
  • Competent and skilled team.
  • Latest technological software and updates. 
  • Reducing your claim denial rates.

For more information, you can look at the different medical billing and coding services we offer in the services section. 

We know that medical billing and coding can take much time, and patient health can be compromised. Outsource your billing and coding services today from Ucontrol billing and focus more on patient care. 


What is the difference between facility and professional billing?

The facility billing is charged for the services provided to the patient related to the facility, like room charges. Professional billing is charged for the services of physicians. 

What is the professional claim in healthcare?

Professional claims are generated by physicians for the inpatient and outpatient services and received from insurance companies.  

What is a professional claim vs institutional claim?

In professional claims, doctors or physicians apply for reimbursement for their medical services to the patients from insurance companies. On the other side, institutional claims involve billing that institutional providers submit to the insurance companies for their services to patients.

The significant difference between the two of them is that professional billing involves medical coding and institutional billing involves medical billing. 

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