Understanding what constitutes facility claims and what doesn’t is a fairly crucial part of submitting your claims properly (and therefore receiving proper reimbursement for the services you’ve rendered), so throughout this article, we’re going to be breaking down all you need to know about these kinds of claims:

Understanding Facility Claims

Put simply, facility claims are basically just any of the charges submitted by your healthcare facility for services that you’ve provided to your patients. These facilities cover quite a broad spectrum, as you’ll see shortly, but in essence, any establishment where medical services are administered should be able to generate facility claims.

Services Encompassed in Facility Claims

Facility claims tend to cover a pretty broad range of services, so let’s take a look at a few of them:

Inpatient and Outpatient Services

These include a massive range of different medical procedures and treatments, from routine check-ups to slightly more complex surgeries. So, whether one of your patients is sent to the hospital for an extended amount of time or even just receives care on an outpatient basis, any of the services you render fall under facility claims.

Laboratory Services

Any kind of diagnostic tests or procedures that you need to do in a lab are obviously pretty integral parts of providing healthcare – from blood tests to imaging studies – so these also contribute to a fairly large portion of the facility claims.

Medical Procedures

Finally (although these three examples aren’t the only examples of facility claims), any medical intervention that takes place in your medical facility – like surgeries or specialized treatments – also makes up part of your facility claims.

Professional Claim Comparison

Generally speaking, the differences between different types of billing can be fairly confusing given how many similarities they might share, but it’s obviously something that you’re going to need to understand if you want to avoid claim denials and subsequent hits to your cash flow.

So, let’s take a closer look at what separates professional and facility (often referred to as institutional) billing:

Scope of Services

Professional billing primarily focuses on all of the fees associated with professional medical services, while institutional billing encompasses broader overhead costs related to facility usage.

Reimbursement Rates

Reimbursement rates for professional claims are typically based on fee schedules and negotiated agreements with insurance companies, whereas institutional claims may be subject to diagnosis-related group (DRG) payments or other prospective payment systems.

Optimizing Revenue Cycle Management

For any small medical practice owners who don’t have the luxury of hiring specialized in-house teams to handle all of your facility claims for you, it can definitely be a bit more challenging to stay on top of your medical billing and coding and ensure accuracy.

Because of this, it’s fairly common practice for smaller organizations, in particular, to outsource their facility claim management to a professional medical billing and coding service like PMN.

Obviously, this is quite a big decision to make when you’re already working on a budget, so let’s take a closer look at what kind of benefits you can expect to receive when partnering with PMN:

Utilize Your Existing Staff Better

Whether it’s for professional or institutional billing, outsourcing lets your physicians go back to their core strengths and continue doing what small practices are known best for – providing treatment with a personal touch.

Compliance and Accuracy

Minimize revenue loss by utilizing an experienced team of medical billers with different specialties to avoid any possible billing errors or accidental regulatory violations. 

Cost-Effectiveness

Hiring and subsequently training in-house billing staff (as well as investing significantly in new infrastructure) is massively expensive if you and your physicians are working in a fairly small medical office, so outsourcing is not only cheaper, but the billing costs are a lot more predictable and easier to plan around, too.

If you’d like to know more about what PMN can do to improve your revenue cycle management – even outside of solely managing your facility claims – we definitely recommend giving one of their supportive team members a call at (949) 215-5055.

Naturally, there can be a pretty big jump from handling all of your medical billing and coding responsibilities to outsourcing it entirely to a third-party company that you’re possibly unfamiliar with, so if you’re still unsure, feel free to book an appointment with their team in person at their office in Laguna Hills, Orange County, California so you can hash out any specific details or ask questions face-to-face instead.

FAQs

What Is The Difference Between Professional and Institutional Billing?

Professional billing is generally more for when individual (often smaller) healthcare providers need to bill insurance companies for patient care directly, which covers things like basic consultations or medical procedures. Institutional billing, on the other hand, tends to cover all the broader operational costs that come with facility usage and overhead expenses instead, like your medical equipment or administrative costs.

How Does The Medical Billing Process Interact With Insurance Companies?

Broadly speaking, the overall medical billing process involves your practice submitting claims to a patient’s insurance company so you’re able to be reimbursed for whatever healthcare services you’ve provided. This means including all the relevant patient information and diagnosis codes that you’ve used so that the insurance companies can take a look at them and process your payment accordingly – possibly letting you know if there are any denials or adjustments you need to make, too.