Group or Individual Contracts: Which One Opens the Network

Network participation comes in two basic shapes. In an individual agreement, the plan contracts with you, under your own tax identification number. In a group agreement, the plan contracts with a practice, and you participate as a clinician credentialed and linked under it. Many clinicians do not know which they have until they leave a job or try to open their own office. The difference decides whether a closed panel is closed to you.

For the narrower question of using a group to get past a closed panel, see joining a participating group. What follows is about the structure itself.

Why do group contracts get around closures so often?

Because the plan has already decided to contract with the group. Adding a clinician changes the plan's count by one person, at rates the plan already agreed to. That is why published closures typically carve out group members. Independence Blue Cross's closed chiropractic and podiatry networks, for instance, both make exceptions "when the provider is joining an existing participating group." Some state laws go further. Texas requires plans to pay a physician who joins an established medical group with a current contract as if in network while credentialing is pending (Tex. Ins. Code 1452.102 and 1452.104). In Texas PPOs, insurers may not withhold preferred provider designation from a podiatrist, optometrist, therapeutic optometrist or ophthalmologist who joins the practice of a contracted preferred provider and meets eligibility terms (Tex. Ins. Code 1301.0521 and 1301.0522).

What do you give up under a group contract?

• Portability. When you leave, your participation through that group typically ends. You may need to apply individually at a time the plan is closed. White Glove Credentialing explains whether credentialing follows you when you change jobs.
• Control of terms. The group negotiates rates and signs amendments.
• Control of disputes. In Medicare enrollment, CMS's Program Integrity Manual says a group's authorized official "cannot sign and submit a CAP and/or reconsideration request on behalf of a reassigned individual physician or practitioner without the latter submitting a signed statement authorizing that official." Know who speaks for you before you need it.

Do federal participation rules treat group physicians the same?

For Medicare Advantage coordinated care plans, yes in one important way: plans must provide participation procedures for "individual physicians, and the management and members of groups of physicians" (42 CFR 422.202(a)), and a plan operating through subcontracted physician groups "must provide that the participation procedures in this section apply equally to physicians within those subcontracted groups" (422.202(c)). Notice, appeal process and, for terminations, the hearing rights in 422.202(d) are not lost because you practice in a group.

One trap for group contracts: a provider contracted with a plan only for its commercial or Medicaid products does not count toward that plan's Medicare Advantage network adequacy (42 CFR 422.116(a)(4)(i)(C)). If your group's agreement covers only some of a plan's products, ask which ones before assuming you are in network for a given member.

How does Medicare reassignment fit in?

Original Medicare is not a network, but group practice affects how you bill it. Clinicians in groups often reassign their Medicare benefits to the group so that it can bill for their services. A change of information or reassignment request is processed within 90 days of receipt (42 CFR 405.818(c)). If you leave, that reassignment has to be ended and your new arrangement set up. White Glove Credentialing covers the mechanics in reassignment of benefits.

Which questions should you ask before choosing?

1. For each major plan, is the group's agreement a group contract, or are clinicians individually contracted and linked?
2. Which products does each agreement cover: commercial, Medicare Advantage, Medicaid, exchange?
3. If you leave, does your participation end immediately, and is the plan open to individual applicants in your specialty and county?
4. Does the employment or affiliation agreement restrict you from holding individual contracts with the same plans?
5. Who will sign and send a reconsideration or dispute if a plan denies or terminates you?

When is an individual contract worth fighting for?

When you plan to own your practice, change employers, or work across several groups, an individual agreement gives you continuity. It is also the harder one to get when a panel is closed. A dispute for an individual contract leans on the evidence covered in documenting an access gap and the levers on the closed panels hub, plus any state law that applies to your situation, listed on the network access laws index.

How do we help?

We review the agreements you are offered for the participation questions above, identify which plans are closed to individual applicants, and prepare dispute letters for the ones worth contesting. You sign and send each one. We are not lawyers; have a healthcare attorney review employment and participation contract terms before you sign. See our pricing for the Network Rejection Review and Payer Network Dispute.