As you build a solo practice or grow into a multiple-provider environment, the administrative structure that will make your money revolves around one thing: Credentialing. Understanding the ins and outs of Solo Practitioner Credentialing vs. Group Practice Credentialing is what makes the difference in how soon you can start seeing patients – and most importantly, getting paid. The CAQH estimates that administrative challenges drain billions from the health care system each year; for the solo practitioner, even one mistake in NPI categorization can bring operations to a halt.
Provider credentialing is the mechanism that connects a provider’s credentials with a payer’s payment method. The objective may be identical (i.e., verifying identification, education, and licensing); however, the legal form alters the approach.
The basic distinction involves delegation of authority and contractual obligations since the group negotiates as one organization, while the solo practitioner negotiates personally.
For the independent healthcare professional, the process of credentialing is personal yet challenging. You are the product, the provider, and the manager.
Under a solo arrangement, you retain total control over your CAQH record and information. You need not depend on the corporate compliance officer to upload the malpractice face sheet. You are assured that the information sent out to the payers will be the one you intend to send.
The “Pro” for control is countered by the “Con” for labor. With no separate credentialing division, the solo practitioner has to monitor the re-credentialing process every 2-3 years, deal with expired licenses, and conduct primary source verifications. “Administrative friction” frequently causes burnout.
The lone provider should have a Type 1 NPI (Individual). But in cases where the lone provider organizes (such as a limited liability corporation/company), they may require having a Type 2 NPI (Organizational) too.
Group methods sacrifice elegance for bulk. The objective in this case is to develop a “roster” method that enables quick expansion.
In a group practice, all providers are connected with the Tax ID of the group. This makes the financial aspect of RCM easier, since the payment is made by the payer to the group itself, rather than making payments to each individual. But this process is very complex because it involves linking the individual with the group (Form CMS-855R for Medicare).
Big groups could be eligible for delegated credentialing. This is where the insurance company delegates the responsibility of performing the primary source verification of the employees’ credentials to the group itself.
The greatest difficulty that the group will encounter is the revolving door of providers. If one of them leaves, then he or she must be “de-credentialed” because any further work can create a situation with fraud. In contrast, when hiring new people, they have to be included right away to avoid “gap periods”.
| Feature | Solo Practitioner Credentialing | Group Practice Credentialing |
| NPI Requirement | Type 1 (Individual) | Type 1 (Providers) & Type 2 (Group) |
| Tax ID | SSN or Individual TIN | Corporate/Group TIN |
| Contracting | Individual Contract | Group/Master Contract |
| Application Volume | Low (Single Provider) | High (Continuous Roster Updates) |
| Negotiation Power | Limited | High (Volume-based leverage) |
| Maintenance | Self-managed | Often outsourced or internal dept |
A solo practitioner is more susceptible to being “panel closed”, which means that the payer argues that there are sufficient numbers of practitioners within a particular zip code. A solo practitioner does not have enough leverage to argue the point since he/she attracts fewer numbers of patients.
Failure to meet deadlines for re-credentialing is the quickest route to cutting off your cash flow. The issue for practices is managing many CAQH profiles at once, numbering more than 50. The issue for individual doctors is just remembering to do it.
Need help navigating these complexities? P3Care specializes in end-to-end credentialing management, ensuring your practice—regardless of size—never misses a deadline or a dollar.
We highly recommend not using the SSN for billing purposes because although it may be legally acceptable for independent practitioners, it is extremely risky. Using an EIN or TIN will keep you safe from being a victim of identity theft and give off a much more professional impression to your payers. For Group Practice Credentialing, the TIN is a must.
Credentialing is the “starting of the engine” of your revenue cycle.
You can also consider switching to group practice credentialing when:
Switching will require a new NPI Type 2 and a Group Practice Enrollment Form for every payer.
We understand that you didn’t choose the medicine to deal with 50 pages of forms, but you’re here to help your patients. Therefore, P3Care takes on the role of your credentialing department, bridging the gap between the care you provide and the paperwork you have to do.
With our expertise in full-cycle medical billing services, we make sure your credentialing process is in perfect harmony with your billing software, preventing the “not credentialed” denial codes that come with most practices.
Solo practitioner credentialing versus group practice credentialing is not just about paperwork but is a business decision as well. Solo organizations might be easier, but group organizations provide the scalability necessary to grow. In either case, accuracy and being proactive are the two greatest safeguards against lost income.
Ready to automate your enrollment? Contact P3Care today for a comprehensive credentialing audit and let our experts streamline your path to reimbursement.
Yes, if the practitioner has incorporated as a legal entity (like an LLC), they should obtain a Type 2 NPI for the business and a Type 1 NPI for themselves.
Standard timelines range from 90 to 120 days. However, if the group has delegated credentialing, this can be significantly shorter.
Credentialing is the process of verifying a provider’s qualifications with a payer. Privileging is the process of a hospital or facility granting permission to perform specific procedures within their walls.
Yes. You have to associate your personal NPI number with the Tax ID for the new group on the “Request to Add” or “Member Change” forms for each payer.
Incomplete forms and expired documents, such as the one regarding malpractice face sheets, are the main reasons for delays, as noted in CMS records.
