I am going from solo to group OR group to solo. Am I still credentialed?
Congratulations! You’re expanding your practice or going out on your own. Whichever route you’ve chosen is one that is likely both exciting and a bit scary.
So, now that you’ve made this decision (or still thinking about it ?) you are probably wondering: What do I do about accepting insurance? Do I need to change anything? Where do I start?
No worries, we will break down the steps for you. Also, feel free to join us in the Mastering insurance Facebook group if you aren’t already a member. We talk about these things all the time.
Leaving a group or organization:
So, lets start with the scenario that you are leaving an organization and want to know if you can take your credentialing with you. The short answer is: maybe. I know, right?! It’s not as cut and dry as we would like. Whether you will be considered in network (INN) at your new practice will depend on:
How you’re currently credentialing matters. Here are the common scenarios.
So, if you are credentialing under a group contract that is affiliated with another agency you will likely have to start the credentialing process for your business. The good news is being an existing INN provider typically reduces your credentialing processing time.
If you are credentialing as an individual under the existing group, you will likely need to do a demographic update. Some insurance companies have a specific form they want you to complete, or they want you to go on their provider portal and electronically submit this update. If an insurance company tells you to submit a demographic update via fax on your letterhead feel free to grab our templates (There’s a $50 off code inside the Mastering Insurance FB community).
How do I find out how I’m currently credentialed?
This is another question that naturally comes up when one begins this process. One approach is to ask the person who handles credentialing at your existing organization. This isn’t always an option, so the alternative approach is to contact the insurance companies directly. You want to contact the Credentialing department (also referred to as Provider Relations) and ask for a copy of your contract. You can also ask them how to update your credentialing from group to solo. Make sure you write down the instructions and ask for a reference number for the call.
You will need an NPI-1, NPI-2 (for your own company), EIN, and a W-9. These documents are commonly requested anytime you are changing your credentialing address. So gather these documents so you’re ready to go. If you’re not sure why you need a both an NPI-1 and NPI-2 check out this blog post that explains it in detail.
You’re a solo practice expanding to a group:
Again, congratulations! This is super exciting for you, your team and the clients your practice will serve. Some insurance companies will allow you to switch your contract from solo to group.
There are two types of group contracts that are typically issued:
- A contract in your Businesses name with the EIN, NPI-2 as billing providers and you are the rendering provider (NPI-1)
- A true group contract where your business is contracted for services. This contract is a bit harder to obtain and may not be available unless you meet certain criteria. Most of us have the contracts listed in #1 and its typically all we need.
Here’s what you want to know when you’re seeking a group contract:
- You want to know whether the insurance company will issue a group contract to your organization. You want to tell them the type of providers you have, how many and what services you offer.
- You want the contract billing and payments to be issued to the group NPI-2 and EIN and if these can be added to your existing credentialing contract (best case scenario as far as processing time)
- Inquire about what they require in order to add additional clinicians to your group. The answer to this question typically highlights whether you have a true group contract. True group contracts typically only require that you add new clinicians to your group roster. Other group contracts typically require credentialing, although the processing time is shorter than solo contracting.
Benefits of asking for a group contract even when it’s just you?
- Easier to add clinicians later on
- Leverage your group status to negotiate higher rates
- Leverage your group status to negotiate better contracting terms
- You’re prepared for expansion
We know that sometimes you want it off your plate. We can handle the credentialing for you. Request a quote here
If you haven’t downloaded our checklists you can grab them here: