A patient says they are covered, and it turns out they are not
A patient books a GP appointment and mentions they have private medical insurance through work. At the desk, they give a membership number but say they will get the authorisation code later. The appointment goes ahead. When your billing team submits the claim, the insurer rejects it: no authorisation, or the policy does not include GP appointments, or the code was for a different service.
Now you are asking the patient to pay an invoice they thought was covered, weeks after the visit. Some pay, some dispute it, and some simply stop responding.
Why codes are collected too late
Online booking forms rarely ask about insurance in any detail, and phone bookings depend on reception remembering to ask. Patients do not always know that many policies need them to call the insurer first and obtain an authorisation code, and that GP cover may be limited or excluded.
Insurers each have their own rules, forms and portals. Healthcode handles much of the electronic billing in UK private healthcare, but it can only process what it is given. If the code is missing or wrong at the point of claim, the problem was created at booking.
What late authorisation costs
| Missing at booking | What happens later |
|---|---|
| Authorisation code | Claim rejected, patient billed after the fact |
| Correct insurer and scheme | Claim sent to the wrong place |
| Cover for this service | Appointment not included in the policy |
| Patient's agreement to pay shortfalls | Dispute when the insurer pays less |
| Details in one place | Billing team chasing reception for notes |
Rejected claims are admin time twice over: once to submit, once to chase, plus the awkward conversation with the patient.
How we move the check to booking
- The booking form, and reception's booking screen, asks self-pay or insured. Insured patients choose their insurer and give membership and authorisation details.
- Patients without a code are sent a message explaining, in wording you approve, that their insurer may need to authorise the appointment, with the insurer's contact route, and a reminder before the appointment.
- Details are checked for format and completeness. Where an insurer provides an eligibility check your billing route can use, we connect to it.
- Reception see each insured booking as complete or missing information the day before, so they can call the patient in time.
- The patient confirms your terms, including responsibility for any amount the insurer does not pay, before the appointment.
- Complete details are passed to your billing route, whether that is Healthcode, your practice system's billing module or your accounts team.
Whether a policy covers a particular appointment is decided by the insurer. The system collects what is needed early and shows what is missing; it does not tell a patient they are covered.
What your billing team sees
Claims arrive with complete details. Rejections still happen, but missing codes stop being a routine cause, and those that do occur are traceable to a patient who was told in advance. Reception do not have to remember every insurer's rules, because the booking step asks the right questions. Patients who turn out not to be covered know before they arrive, and can choose to self-pay or rebook.
Over time you also build a clearer picture of your insured work: which insurers your patients use most, which ones reject most often and why. That helps when you decide how prominently to promote insured appointments, and it gives reception better answers when a patient asks whether their insurer is one you work with.
Is this where your claims fail?
- Insured patients are seen before authorisation is confirmed
- Rejected claims mean billing patients weeks later
- Booking forms do not ask for insurer details
- Reception chase codes on the day of the appointment
- Shortfall terms are not agreed before the visit