Reimbursement Rates: Different in Solo vs. Group Practices?

If you’ve ever compared notes with another therapist and thought, “Wait…how are you getting that rate?” — you’re not alone. Reimbursement can feel mysterious, even when you’re doing the same CPT codes, in the same city, for the same payer.

Here’s the honest answer: sometimes reimbursement rates are effectively the same for group and solo practices, and sometimes they’re meaningfully different. The “why” usually comes down to how the payer sets rates, who’s contracted, and what identifiers and billing structure are used.

Let’s break it down in a practical way.

When rates are usually the same

1) Medicare (and anything pegged to Medicare)

For Medicare Physician Fee Schedule services, the payment methodology is standardized: it’s based on RVUs (work, practice expense, malpractice), adjusted by geography, and converted using a conversion factor. In other words, Medicare is far less about “who negotiated better,” and far more about “what code, what location, what setting.” (Source)

That doesn’t mean every detail is identical in real life (place of service and facility vs. non-facility can matter), but being solo vs. group isn’t typically the driver.

2) Medicaid fee-for-service (often)

Many state Medicaid programs publish fee schedules, and reimbursement is frequently tied to:

• CPT/HCPCS code
• provider type / specialty
• location / state rules
• place of service

If a payer is using a published schedule, your practice size alone may not move the number much. Where it can change is managed care (MCOs) or value-based arrangements, which can vary more.

When rates can differ a lot

1) Commercial insurance: negotiated rates

Commercial payers commonly set rates through contract negotiations with behavioral health providers or groups, and those rates are usually confidential.

This is where group practices can have an advantage, because a larger group may bring:

• more covered lives served (patient volume)
• more leverage in a local market
• more covered service breadth (multiple specialties, locations)
• stronger operational credibility (clean claims, lower admin friction)

Research and policy analytics regularly describe commercial prices as driven by negotiating dynamics. Studies show sizable variation by market and practice characteristics. (Source)

Translation: two clinicians can bill the same code and still have different allowed amounts because their contracts differ.

The variables that most commonly drive “same vs different”

Think of reimbursement like a formula. Practice size is just one input, and often not the biggest one.

A) Payer type and plan design

• Medicare reimbursements tend to be standardized.
• Commercial insurance reimbursements are heavily contract-based. (Source)
• Medicaid reimbursements depend on fee schedule vs managed care contracting (varies by state/payer).

B) Geography

Even in Medicare, geography matters because payment is adjusted by regional cost indices.

Commercial rates can also swing dramatically by region and local market power dynamics. (Source)

C) Contracting entity and billing structure (solo NPI vs group NPI)

A key operational detail: who is the “billing provider” on the claim and which provider NPI is used.

• Type 1 NPI = individual clinician
• Type 2 NPI = organization (group / entity)

Many groups bill under the organization’s Type 2 NPI while still listing the clinician as the rendering provider. That structure can affect payer credentialing setup, how payers load you in their system, and sometimes which contract rates apply. (Source)

D) Rendering vs billing provider details

Even when the rendering clinician is the same, the billing entity can change (solo vs group). This is why claim configuration matters: payer systems care deeply about these roles, and mismatches can trigger denials, rejections, or unexpected reimbursements.

Practical examples

Example 1: Same rates (common)

A solo therapist and a group therapist both bill the same CPT code to Medicare in the same geographic area, same place of covered service.

• Same code
• Same locality
• Same Medicare methodology

Result: reimbursement is usually the same, or extremely close.

Example 2: Different rates (very common)

A solo therapist is contracted directly with a commercial payer. A group practice negotiates a different contract with the same payer.

• Same code
• Same city
• Different contracts

Result: allowed amounts can differ, sometimes materially, because commercial prices are negotiated. Congressional Budget Office+1

“Should I expect higher reimbursement if I join (or start) a group?”

Sometimes yes, but the answer depends on several variables.

What often does improve with a well-run group is your ability to:

• negotiate (or renegotiate) rates with better data
• diversify payer mix
• reduce avoidable claim denials (clean claim operations)
• standardize fee schedules across the entity

And even if the contracted rate doesn’t jump overnight, groups sometimes see better net collections simply because their billing workflows are tighter.

If you would like a simple checklist of what usually matters most for reimbursement outcomes, prioritize these:

• Are you contracted with the payer under the right entity (Type 1 vs Type 2)?
• Are rendering + billing provider fields correct on claims? Source
• Do you know your top 10 CPT codes and their allowed amounts per payer?
• Do you have denial trends by payer and reason code?
• Can you show the payer why your rates should change (data + volume + access)? Source

A warm (but important) closing note

If reimbursement feels confusing, it’s not because you’re missing something obvious. It’s because payment is a mix of policy (Medicare/Medicaid), negotiation (commercial), and mechanics (credentialed and enrolled + NPIs + claim fields).

At CheckpointEHR, we firmly believe that providers shouldn’t have to “guess” their way to healthy cash flow. The more clearly you can see your payer mix, allowed amounts, and denial patterns, the more confidence you’ll have — whether you’re solo, group, or somewhere in between.

Want a practical next step? Pull a report of your top CPT codes by payer and compare:

• charges vs allowed vs paid
• denial rate by payer
• days to payment by payer

That one snapshot will usually tell you more than a dozen hunches.