How to Start a CRNA Group

To start a CRNA group, you form a business, get a Type 2 NPI, and enroll with Medicare and other payers. You also sign facility contracts, buy malpractice insurance and set up billing.

The steps overlap, and enrollment takes time. Start the paperwork months before your first case. This page gives the order of operations and what to check at each step.

Step 1: Check what your state allows

Before anything else, confirm how CRNAs can practice in your state and at your target facilities.

• State law. Your board of nursing sets CRNA scope and any supervision or collaboration rules. See our board of nursing directory.
• Medicare opt-out. Hospitals must have CRNAs supervised by the operating practitioner or an anesthesiologist unless the state has opted out. As of September 2026, 27 states plus DC and Guam have opted out. See CRNA opt-out states.
• Facility bylaws. Each hospital or surgery center has its own medical staff rules for CRNAs.

These rules shape which facilities you can serve and how you document supervision.

Step 2: Form the business entity

Choose an entity type with a health care lawyer and a CPA. Options include an LLC, a professional LLC or a professional corporation. State law may require a particular entity type for licensed clinicians.

Get a federal Employer Identification Number (EIN) from the IRS. Open a business bank account, and keep group money separate from personal money.

Also decide early:

• Who owns the group, and how profits are split
• Whether CRNAs will be W-2 employees or 1099 contractors (see our 1099 CRNA guide)
• How decisions are made, and what happens when an owner leaves

Put this in an operating or shareholder agreement.

Step 3: Get a Type 2 NPI

Each CRNA already has an individual (Type 1) NPI. The group needs its own organizational (Type 2) NPI, which you apply for through NPPES.

CMS says organizations, including single-member LLCs with an EIN, use a Type 2 NPI. Sole proprietors are treated as Type 1. Medicare's group enrollment form requires a Type 2 NPI.

Step 4: Enroll with Medicare

Medicare Part B pays for anesthesia services by a CRNA who is legally authorized by the state. Payment can go to the CRNA or to an entity the CRNA works for or contracts with.

Enroll the group

The group enrolls as a Clinic/Group Practice using the CMS-855B, or online through PECOS.

Enroll each CRNA

Each CRNA must be enrolled using the CMS-855I. A CRNA must be enrolled before a reassignment can take effect.

Reassign benefits to the group

Each CRNA then reassigns their Medicare benefits to the group. This lets the group bill and be paid for services under the CRNA's NPI.

CMS now handles reassignments through the CMS-855I. The old CMS-855R form has been discontinued.

Know how Medicare pays CRNAs

• Payment is based on base units plus time units, times an anesthesia conversion factor set by CMS.
• CRNA services are paid on assignment only.
• A CRNA working without medical direction by a physician reports the QZ modifier.

Step 5: Enroll with Medicaid and commercial payers

• Medicaid. Each state runs its own enrollment. Apply for the group and each CRNA.
• Commercial plans. Many use the CAQH Provider Data Portal for provider data. Then each plan has its own credentialing and contracting steps.

Getting credentialed means a plan has verified you. Getting a contract sets your rates. You need both to be paid in-network. See APRN credentialing.

Commercial contracting can take a long time. Ask each plan for its timeline. Avoid scheduling its members until you are in-network or have a plan for out-of-network billing.

Step 6: Sign facility contracts

Your group needs a written agreement with each hospital or surgery center you cover. Key terms to negotiate:

• Coverage. Which rooms, days, hours and call you will staff
• Exclusivity. Whether you are the only anesthesia group at the facility
• Billing. Whether you bill payers directly, the facility pays you a fee, or both
• Stipend. Whether the facility pays a subsidy if collections do not cover your costs
• Quality and reporting. What data you must share
• Term and termination. How long it lasts and how either side can end it

Every CRNA must also be credentialed and privileged at each facility before working there.

Step 7: Get malpractice insurance

Decide whether the group buys a policy covering all CRNAs, or each CRNA brings their own. Facilities may set minimum limits in their contracts.

Choose between occurrence and claims-made coverage, and plan for tail coverage. Read CRNA malpractice insurance.

Step 8: Set up billing and collections

Anesthesia billing has its own rules, including time reporting, base units and modifiers. Errors lead to denials, delays and compliance risk.

You can bill in-house or hire a billing company. Either way, track:

• Clean claim rate and denials, by payer
• Days in accounts receivable
• Collections compared with what you expected

You can read a detailed step-by-step guide to the billing side.

Step 9: Build your operations

• Compliance. Written policies for documentation, billing and HIPAA
• Scheduling. How you cover vacations, sick days and call
• Hiring. W-2 vs 1099, pay, benefits and non-compete terms (see CRNA contract negotiation)
• Recruiting. Post openings on our job board

Order of operations

Some steps depend on others, so the order matters:

1. Check state rules and facility bylaws.
2. Form the entity and get the EIN.
3. Get the Type 2 NPI, which Medicare group enrollment requires.
4. Enroll the group and each CRNA with Medicare, then file reassignments.
5. Enroll with Medicaid and start commercial contracting.
6. Sign facility contracts and buy malpractice cover.
7. Complete facility credentialing and privileges for each CRNA.
8. Set up billing before the first case.

Processing times vary by state, payer and facility. Ask each one for its current timeline.

FAQ

Can CRNAs bill Medicare without an anesthesiologist?

Yes. Medicare pays for CRNA services, and payment can go to the CRNA or their group. Supervision rules still depend on the state, facility and opt-out status.

Do I need a Type 2 NPI if I work alone?

It depends on how you are set up. CMS treats sole proprietors as Type 1, while an LLC with an EIN uses a Type 2 NPI. Ask your CPA and lawyer.

Is the CMS-855R still used?

No. CMS has discontinued it. Reassignments are reported on the CMS-855I.

This page is general information, not legal, tax, billing or financial advice. Work with a health care lawyer and CPA.

Sources

• eCFR: 42 CFR 410.69, services of a CRNA
• eCFR: 42 CFR 414.60, payment for the services of CRNAs
• eCFR: 42 CFR 414.46, payment for anesthesia services
• eCFR: 42 CFR 424.80, reassignment of claims
• eCFR: 42 CFR 482.52, hospital anesthesia services
• CMS: Form CMS-855B, clinics/group practices and other suppliers
• CMS: Form CMS-855I, physicians and non-physician practitioners (reassignment; CMS-855R discontinued)
• CMS Medicare Claims Processing Manual, Chapter 12 (anesthesia modifiers)
• NPPES (National Plan and Provider Enumeration System)
• CMS PECOS (Medicare enrollment)
• DataSpring (CAQH): For Clinicians
• AANA: Fact sheet concerning state opt-outs (September 2026)

Disclosure: Nelson is a founding adviser to Titrate Revenue, a US anesthesia billing company.