Group Contracts vs. Individual/Solo Contracts with Insurance Payers
- 2 hours ago
- 2 min read
The first question I ask clients is do they want to have the flexibility to add/credential another provider with their practice at any point in the future. This guides us to determine what the next steps are and how they should credential their practice.
If the answer is yes, then we need to make sure they have a group NPI. The group NPI
When you credential with the insurance payers, you can enter into a contract using your Individual NPI (type 1): Individual/solo agreement
OR
Group NPI (Type 2): Group contract
If you choose to credential as an individual and enter into solo agreements with each payer, you can use either your SSN or your TIN (if you have a business). You don't need a group NPI. A huge misconception people have is they can contract as an individual for now and then switch to a group later. Although this is possible, it would require you to re-credential with each insurance payer which would cost you more money and disrupt billing.
Deciding to organize as a group just means that you need a type 2 NPI and a TIN. In addition, if you want to be in network with KY Medicaid, you would also need a KY Medicaid Group ID.
Some insurance payers (Cigna and United Healthcare) only allow group contracts for practices/entities that have 5+ providers on the roster to be credentialed. This doesn't mean you can't credential with these payers. You would enter into a individual agreement, but still use your group NPI on the credentialing documents which indicates you are billing under the group as the "billing provider."
What is the Billing Provider?
The billing provider information on the CMS 1500 is in box 33:
If you are using an Electronic Health Record (I HIGHLY recommend using an EHR- click here for a discount link with SimplePratice), during setup you want to make sure you use your inputting the correct information depending on how you were credentialed. This information pre-populates on the claim forms.
Group NPI/Group contract= business name and group NPI when adding your billing provider information.
Individual/Solo Contract= individual name or business name, individual NPI, individual taxonomy code