Medical CodingPhysicians/ Doctors

Hospital Billing vs. Clinical Billing


Two kinds of billing exist in the medical billing genre – Hospital billing (institutional billing) and clinical billing (physician billing). Hospital billing refers to the billing of claims generated for services performed by doctors who are associated with a hospital and for patients that make use of outpatient/inpatient services, diagnostic procedures, emergency services, laboratory, medication, oxygen services, several therapies and radiology services. Clinical billing refers to the billing of claims generated for the services performed by individual physicians which includes lab tests, procedures and minor surgeries, and by other non-institutional providers to a patient.

Factors that differentiate both the billing systems are:

1. Billing and Coding: Physicians typically work with one medical billing professional for billing and coding purposes. A primary reason is that working with several billing professionals would lead to a chaos and the questioning by insurance providers on claims would create confusion along with taking a longer turnaround time on reimbursements. A single window would also lead to a reduction in errors as a single billing expert would be able to give more time to detect and rectify mistakes if any.

2. Processing time: As a physician is mobile in their services, they prefer to record all their details in one area rather than asking the hospital’s billing department to do the same which could take longer for processing. The insurance industry is also well versed with people who are experts themselves in hospital and clinical billing. Also, physicians see lesser patients than a hospital. Hence, the independent physician prefers billing separately as this not only speeds up the process, it creates lesser hurdles and increases the turnaround time for reimbursements. For hospitals, the insurance company works as per the hospitals’ norms which could delay a physician’s bill (who works with a hospital). And as a hospital has investors and operating capital, they can wait for the claim to come through, whereas independent practitioners wouldn’t want to. Billers and coders are two different entities in hospitals. For independent physicians, it is usually one biller with physicians sometimes doing the coding themselves.

3. Form: Clinical billing is usually prepared on a CMS-1500 form. It’s a claim form consisting of red ink on white paper and is used by suppliers and physicians. The electronic version of the form that is accepted by Medicare, Medicaid and other insurance providers is known as 837-P where P implies the professional format. Institutional or hospital billing is usually prepared on a UB-04 (Universal Bill). It is a similar colored form and the electronic version is known as 837-I where I stands for institutional billing.

4. R&C: Both are paid according to a reasonable and customary (R&C) amount. In the case of clinical billing, this amount is based on aggregate data from multiple insurers whereas in hospital billing, this amount is based on industry data or by the mutual contract formed between the hospital and the insurance provider.

All in all, whether hospital billing or clinical, both have their specific demands that either make it more simple or complicated. And hence, medical billing on a whole needs professionals who continuously keep abreast with the ongoing trends and regulations.

Medical Billers and Coders

Catering to more than 40 specialties, Medical Billers and Coders (MBC) is proficient in handling services that range from revenue cycle management to ICD-10 testing solutions. The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.

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