How to handle insurer authorisation and invoicing in a private clinic

Insurer authorisation and invoicing in a private clinic come down to three habits: collect the patient's membership number and pre-authorisation number in writing when the appointment is booked, check both before the first session, and invoice straight after each one. An insurer invoice can come back because of a number missing or in the wrong format, or a session beyond those authorised, which could have been known at booking. An AI worker can collect, check and chase. What an insurer will cover is the insurer's decision, and whether a patient is billed for a shortfall is your practice manager's.

What changes when a patient says they are insured?

A patient says "I'm going through my insurer". From then the clinic has two customers for one appointment, and the second pays only if the paperwork matches its records.

How does an insured appointment go from booking to payment?

1. The numbers. Reception asks for the insurer, the membership number and the pre-authorisation number, often by phone and onto a note.

2. The check. Someone confirms the membership, by a call to the insurer or through Healthcode, which matches a patient's details against participating insurers' records.

3. The treatment. The clinician treats and records the session.

4. The invoice. The practice manager raises it with both numbers on it. AXA Health, for one, requires a recognised physiotherapist to submit every invoice electronically, through Healthcode or another billing system it recognises.

5. The format check. Healthcode validates the number's format for most insurers and publishes the formats that pass. AXA Health does not validate it. A Bupa pre-authorisation number is digits only. A VitalityHealth one is six to eight digits beginning 1, 5 or 9.

6. Payment and the shortfall. The insurer pays in full, in part or not at all. Healthcode is plain that a pre-authorisation number is not a guarantee of payment. An excess, or a shortfall where your terms with the insurer allow, is then the patient's to pay and the clinic's to ask for.

7. The end of the authorisation. If the insurer authorised a set number of sessions, someone must notice when the last is used.

How to stop rejections at booking

• Ask in writing, at booking. A booking confirmation that asks for the insurer and both numbers gets them typed by the patient, not copied from a phone call.

• Keep the formats beside the diary. Print the formats Healthcode publishes and check each number as it arrives.

• Tell the patient about shortfalls first. Put one sentence in the confirmation, worded to fit your terms with each insurer: the excess, and anything the policy does not cover, is the patient's to pay. The later request then reads as a reminder of something already said.

• Invoice the same day. A week's invoices done on Friday afternoon are a week's errors found the following Friday.

• Record what was authorised. Put the sessions and dates on the record, where clinician and reception both see them.

Which parts can an AI worker take on?

An AI worker here works to a single written job, with a named person at the clinic checking its work and a review each month. It can ask an insured patient for the insurer and both numbers when the appointment is booked, and remind them before the day if either is missing. It checks each number against that insurer's published format, where there is one, and asks again where it does not fit. After each session it prepares the invoice for your practice manager to check and send. It keeps a list of sent invoices and their state, reminds your practice manager of those unpaid past the days you set, and sends patients your approved message about a shortfall once a person has decided it is to be billed. It warns reception and the clinician when a patient's authorised sessions are nearly used. The role is set out on invoice and payment chasing. Consent forms, enquiries and the rest of the front desk's work are on our page for private clinics.

Who decides cover, clinical answers and shortfalls?

• Cover. Whether a treatment is covered, and for how many sessions, is between the patient and the insurer. The agent never tells a patient they are covered.

• Anything clinical the insurer asks for. A report, a diagnosis or a request for more sessions is the registered clinician's to write. The agent says a request has arrived; it does not answer it.

• Sending, billing and disputes. The practice manager checks and releases each invoice, and decides whether to bill a patient, write an amount off or argue a rejection.

• Phone calls and the membership check. Calls to an insurer, and the check in step two, stay with a person, because the agent works in writing.

• The data decisions. The ICO gives an invoice for a series of physiotherapy sessions as an example of information that reveals a person's health. What the agent may see, and on what basis, is the clinic's decision, written into the role first.

• A patient describing symptoms. Any such message goes to a clinician, unanswered by the agent.

What to have on the table first

• The insurers your patients use, and your recognition terms with each.

• Last quarter's rejected invoices and the reason for each.

• How invoices leave your booking system today, and who sends them.

• Your wording on shortfalls, and the days after which an unpaid invoice is chased.

• Who decides on a shortfall, and who is told when authorised sessions run out.

How this work limits the number of appointments a desk can support is in our article on scaling a private clinic without hiring more staff.

For a clinic with an insured caseload, an AI worker would collect the numbers, check their format and keep every insurer invoice moving, and your practice manager would decide what is sent and what is billed. Rejected invoices can eat a practice manager's week. Talk to our agent.