Individual Credentialing vs. Group Credentialing as a Private Practice Therapist: a Cautionary Tale.

Getting credentialed with an insurance company is necessary if you plan to see patients who plan to pay with their health insurance. The aim is to become “in network” within an insurance platform, “Yes, I do take Blue Cross Blue Shield!” This way, after the service you can bill the insurance for your fee, and the client will only be responsible for their co-pay. It is important to be aware that not all credentialing is the same, and how you get credentialed will matter in the long run. 

Misunderstanding the difference between individual and group contracting with insurance companies

This is my cautionary tale that I share so that you won’t make this mistake also. When I first left the community health setting, I joined a group practice. This employer had staff that took care of billing, intakes and credentialing with insurance companies; I just had to sit back, and do the work I wanted to do — psychotherapy, plain and simple. I had no idea how to bill or work with insurances anyway, so this was the dream! 

I was told I was credentialed with all of the majors, and I thought that I was INDIVIDUALLY credentialed, because I was the person seeing the clients. In reality, I was credentialed under the GROUP practice. When I left to form my own private practice, I was surprised to find out that I was not credentialed within of the insurances, and that I could not submit any claims.

The confusion between individual vs group credentialing

Where did I make my mistake? I did not understand the ins and outs of the EIN and the NPI and how the credentialing process works. If you are individually credentialed, this is under your own TAX ID and National Provider Number. That means that wherever you decide to practice, this is your special accreditation. I thought it was the NPI that secured the credentialing, but the Tax ID is a large factor in this as well! 

On the flip side, if you get credentialed under a group, this is a group of practitioners working under the same Tax ID (under one business) and the insurance company accepts the business and all who work within it. This is beneficial for the business, because people cannot move around as easily or leave on a whim if they want to practice on their own. 

How do I get contracted individually with insurance companies if I am already contracted with a group?

If you find yourself working under a group practice, and you want to go independent, have no fear. It’s going to be a bumpy ride, but it’s not impossible to switch to an individual contract. First, decide which insurance companies will be worth pursuing on your own. Maybe pick three to keep your head straight.  Then get on the phone with provider services for each insurance and find out what they want you to do. Some insurance companies will make this easy, some will require you to begin the application from scratch. 

Remember that you are already in their system as an in-network provider. THIS WILL CONFUSE THE INSURANCE PROVIDER SERVICES REPS. Clarify that yes, you are in network, but not in the way you need to be. CAQH will not reflect the differences either. Its up to you to keep track of where you are credentialed and what applications you are still waiting on. Also, some insurance companies have State Representatives that can be very informative and helpful to expedite your paperwork along. 

What is the point of group contracting with insurance companies?

You may be asking, why is group contracting even a thing? Who would choose to be contracted under a group in the first place? It turns out, it is actually somewhat uncommon to get caught up in a group contract; so much so, that many customer service reps at health insurance agencies did not understand what I was trying to untangle. I didn’t want to think negatively about my past employer that gave me my first job after getting licensed. But with time, and talking to others that have gone through it, I have realized that there is only one reason a group practice would choose to contract you in this way— to keep you there and make it difficult to leave. They invest a lot into a new employee, and losing you is a big deal. By closing you in with their contracts, it feels impossible to leave. Had I known that I would run into this situation, I may have not left that job so quickly.

But is it worth it to join group therapy practices?

I know what I am going to write here will not resonate with others; but I truly wish that I did not join a group practice after leaving community health. I was not fully informed about my options as a licensed therapist. What is interesting, is that these middleman group practices sell themselves by advertising that they can get your started as a counselor running your own business. “You can make your own hours, you can choose who to work with, you can take as much time off as you want — and we will cover all of the logistics” But at a price. It’s the Little Mermaid all over again: we can get you what you want and it will be amazing at first. Whoops… you sold your soul and now you owe us everything; and we profit off of your hard work. Ok, that is a harsh way to put it. But you get what I mean.

If there was one thing that I needed to know, and would have changed the way I started the business, it would be this. All was made right with a bit of time, but the headache it caused still lingers. If you find that you need emotional or practical support on this, please don’t hesitate to contact me!

TL;DR

When it comes to getting contracts with insurance companies, there is a big difference between individual contracts and group contracts. If you have worked for a group practice, make sure they have not contracted you under their group.

This is because your contract is not related to your NPI, it is related to your EIN! If you change jobs, your NPI stays the same, but your EIN does not.

To untangle this mess, you need to contact each insurance company individually and ask what their process is for fixing this. Some will make it easy, most will make you begin the contracting application from scratch. Many will have no idea what you are talking about.