Everything a Group Practice Needs to Run as One Practice

The group needs its own identity before any provider can bill under it. A practice organized as a corporation, partnership or other business that the state treats as separate from an individual applies for an organizational NPI, Entity Type 2. The organization must also get an NPI for any subpart that would be a covered health care provider if it were a separate legal entity, and it may get NPIs for other subparts that qualify, such as a location that bills separately. Each provider keeps their individual, Type 1 NPI wherever they work.

Medicare enrolls clinics and group practices on the Form CMS-855B, with every practice location listed. For physician and practitioner organizations, Medicare billing privileges start on the later of the date the application is filed or the date services begin at a new location, with a limited retrospective billing window, so the group's enrollment has to be filed as soon as the entity, tax ID, NPI and location are ready. Enrollment is revalidated every five years.

Each provider must be enrolled in Medicare as an individual before reassigning their benefits to the group, and both the provider and the group must be enrolled, or enrolling at the same time, before the reassignment takes effect. Reassignment used to have its own form, the CMS-855R. CMS has discontinued it: reassignments are now added, changed or ended on the Form CMS-855I, or in PECOS, with a separate reassignment for each group a provider bills through.

Commercial payers have their own version of the same link: the provider is credentialed individually and then added to the group's contract. A provider who is credentialed but not linked to the group can cause claims to deny, and a provider who leaves but stays linked can leave the group exposed. We handle both sides with every payer, and confirm the effective date before the provider's first claim.

For Medicare Advantage plans, CMS requires credentialing of every physician who serves the plan's members, including members of physician groups, and of other professionals who practice independently under state law, with recredentialing at least every three years.

Some payers let a qualified group credential its own providers under a written delegation agreement, instead of sending every new provider through the payer's own process. The payer stays responsible for overseeing the work. For Medicare Advantage plans, federal rules spell out what the delegation contract must say: which activities are delegated and what the group reports, how the delegation can be revoked if the group does not perform, that the plan monitors performance on an ongoing basis, and that the plan either reviews the credentials itself or reviews and approves the group's credentialing process and audits it on an ongoing basis.

Whether delegation makes sense depends on how many providers you add each year and which payers offer it. We help you weigh it, build the credentialing files to the payer's standards, primary source verification included, and keep the records and reports the payer's audits look for.

A new hire who starts seeing insured patients before their enrollment is effective creates claims that cannot be paid. The fix is to start early and in order: confirm the state license, DEA and state controlled substance registrations, collect the documents once, enroll the provider in Medicare and reassign to the group, credential with each commercial payer and link to the group, then release the provider's schedule payer by payer as approvals arrive.

For nurse practitioners and physician assistants, onboarding also includes the collaboration or supervision agreement your state requires. Groups that see patients in more than one state, in person or by telehealth, need each provider licensed and registered in every state where their patients are located, and we track every license, registration and renewal across the roster. We run this checklist for every hire, report status by payer, and hand each effective date to billing.

A new location is a change with every payer, not only a new lease. The location is added to the group's Medicare enrollment, with Medicare billing privileges there starting no earlier than the filing date or the date services begin at that location, whichever is later. Each commercial payer needs the new address, and sometimes a new contract or a new group record. If the location will bill separately, it may need its own organizational NPI. The HIPAA risk analysis, the EHR and the patient portal all need the new site added before it opens.

Departures need the same care in reverse. When a provider leaves, we end the reassignment, remove the group linkage with each payer, close any collaboration or supervision agreement, and make sure the provider's open claims are worked before the account is closed.

A group's billing has to get the rendering provider, the billing entity and the location right on every claim. Our billing team runs one revenue cycle for the whole group: eligibility before the visit, coding against the note, claims checked for the right rendering and billing NPIs, payment posting, denials and A/R follow-up. Every month you see charges, collections, A/R aging and denials by payer, provider and location.

Groups with physicians and nonphysician practitioners need two Medicare rules applied correctly. Incident-to billing requires the physician to start the course of treatment, stay actively involved and provide direct supervision, or general supervision for behavioral health services. In facility settings, a split or shared visit performed by a physician and an NPP in the same group is billed by the practitioner who performed the substantive portion, which since January 1, 2024 means more than half of the total time or the substantive part of the medical decision making.

Running every location on one system makes the rest of the work possible. Our EHR gives each provider specialty templates, scheduling across locations, online intake, e-prescribing including controlled substances, and claims created from the visit, connected to the patient portal, telehealth and payment processing.

We set it up for each location and provider, move records over from your current system, and set role-based access so each person sees what their job requires.

HIPAA applies to the group as one covered entity, and its risk analysis has to cover every system and location that holds electronic patient information. The group also needs a designated security official, written policies that every location follows, training for the entire workforce, management included, and a business associate agreement with each vendor.

Multiple locations make drift easy: one office adopts a new texting tool, another keeps paper intake forms in an unlocked room. We run the risk analysis across every location, write one set of policies, train every hire at onboarding and every year, collect BAAs for every vendor, and repeat the analysis whenever you add a location or a system.