Group vs. Individual Credentialing: What’s The Difference?

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Insurance Credentialing is one of the most complex parts of starting or growing a practice. Luckily there are two viable options for credentialing your practice based on your needs. You can credential your practitioners as individuals or you can credential your whole practice as a group. Both options require a similar application process and end with your practice getting credentialed. So what’s the difference?

The Process

The process for both group and individual credentialing is very similar. You will have to turn in an application for practitioner(s) including their resume, areas of expertise, work history and much more. Then you’ll submit these applications to individual insurance companies with the hopes that your application is complete and the panel isn’t closed or full (internal link).

If your application is done right, the credentialing process phase takes around 60-180 days. Your application is key to getting credentialed; any missing or incorrect information could add weeks on to the process. Along with your application some insurances require a CAQH for group and individual applicants.

Each application follows these three steps: First, the application is reviewed for completion and supporting documents. Second, practitioner’s credentials are verified. And third, the application goes through a review. This review is dependent upon each insurance but is usually comprised of clinical staff and peers. The application is the most tedious part of the credentialing process.

The Individual

Practitioners looking to get credentialed individually open up their ability to move between practices with relative ease. When you are credentialed individually insurances will accept you regardless of what practice you’re with. This is because you’ve been given your own tax ID number to bill through, separate from your practice.

Individuals must meet all criteria set forth by the insurance company and they will only be credentialed for specialties they are licensed in. Individual credentialing is very specific in what will and will not be covered by insurance. But being individually credentialed gives more freedom and flexibility than a group credentialed practice.

The Group

While some practitioners prefer to be individually credentialed it is also worth looking into credentialing as a group. When a group is credentialed each practitioner must submit their information in one big application. Each practitioner must meet the requirements of the credentialing panel before the group will be accepted.

One of the biggest benefits to being credentialed as a group is that if one of the groups providers leaves the practice/group, the credentialed enrollment doesn’t go with them. Therefore, groups aren’t paying to credential their employees only have them leave.

The Compromise

Both individual and group credentialing provide great options to fit your practice’s needs. But there is also a third option that sits in the middle of these two. Some insurance agencies give the option for practitioners to credential individually but connect with a practice’s tax ID number.

Insurance credentialing is a tricky business, there are multiple options to research before deciding which credentialing style and insurance companies will be most beneficial for you. Insurance credentialing is becoming more commonplace as access to healthcare grows and different coverage options become available. Credentialing is saving patients money and making sure that your practice is available to those who need it most.