Insured vs Self-Pay Patients in Private Practice: How to Manage Both
For most UK consultants running a private practice, the patient caseload is a mix of two quite different funding types: those covered by private medical insurance (PMI), and those paying directly from their own pocket. Both groups are growing. Both require a different administrative approach. And confusing the two, or failing to manage either properly, creates a particular kind of friction that erodes the patient experience and creates avoidable cash flow problems for the practice.
This article sets out how the two models work in practice, what consultants need to do differently for each, and how to build administrative systems that handle both without constant manual intervention.
Key Takehome message
Identify payment type at booking, confirm pre-authorisation for insured patients, disclose fees in writing for self-pay, use correct codes, and submit insured invoices promptly through Healthcode
The Current Picture: A Market Driven by Both Payment Types
Understanding the scale of both payment types helps calibrate where administrative effort should be focused.
On the insured side, the Association of British Insurers (ABI) reported that health insurers processed a record £4 billion in individual and workplace PMI claims in 2024, a 13% increase on 2023. The total number of people who claimed on either an individual or workplace policy reached 1.8 million in 2024, up 10% on the prior year. According to Broadstone's analysis of the FCA's Financial Lives Survey, approximately 14% of UK adults now hold PMI, equating to around 7.6 million people, up from 6.7 million in 2020. The employer-sponsored market is driving much of this growth: the ABI recorded a record 4.7 million people covered by employer PMI schemes in 2023, the highest in over 30 years of data collection.
PHIN data for the full year 2024 shows insured hospital admissions reached 664,000, a 6% rise on 2023 and a new record high. Looking further into 2025, Healthcode, the official UK clearing organisation for private medical invoices, processed 11.8 million invoices across the year, generating £7.5 billion in revenue for the sector. The fourth quarter of 2025 alone saw 3 million invoices processed, up 5% on both the prior quarter and the same period in 2024.
Self-pay, meanwhile, remains substantial despite a period of softening from its post-pandemic peak. PHIN recorded 275,000 self-pay admissions in 2024, the third highest annual total on record, behind only 2023 (283,000) and 2022 (276,000). Self-pay activity remains significantly above pre-pandemic levels, up 38% compared to 2019. The most common procedures chosen by self-pay patients include cataract surgery, hip and knee replacements, and a range of general and gynaecological procedures.
In practical terms, this means most established private practices are handling hundreds of insured and self-pay patients each year, often on the same clinic list, often with very different administrative requirements running in parallel.
Sources: ABI: Private Medical Insurance Data | PHIN: Market Update June 2025 | Healthcare Today: Healthcode 2025 data
The Insured Patient Pathway: How It Actually Works
Many consultants, particularly those newer to private practice, are not fully familiar with the insured patient pathway from the patient's perspective. Understanding it clearly reduces friction and avoids the most common administrative errors.
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The referral and pre-authorisation process
In most cases, an insured patient's journey into private care begins with their NHS or private GP, who writes a referral letter specifying the type of specialist needed. This is typically an "open referral," naming the specialty required rather than a specific consultant. The patient then contacts their insurer's claims line, provides their policy and referral details, and the insurer checks whether the condition and proposed treatment are covered under their policy. If they are, the insurer issues a pre-authorisation code, sometimes called an authorisation number or approval code, which the patient provides when booking their appointment.
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Pre-authorisation matters enormously from an administrative standpoint because without it, treatment costs may not be reimbursed. Insurers will not typically pay invoices that were not pre-authorised, and the responsibility for ensuring authorisation is in place before treatment begins sits with both the patient and the practice. Straightforward requests are often authorised quickly by phone. More complex cases, or those requiring additional clinical information, may take several days.
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Once the authorisation code is in place, the patient attends their consultation. From that point, any further investigations, procedures, or follow-up appointments may each require their own authorisation, which your administrative team will typically obtain on the patient's behalf by contacting the insurer directly.
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Insurer recognition: the prerequisite for insured work
Before you can treat insured patients and expect your invoices to be settled, you need to hold recognition with the relevant insurers. The major UK private medical insurers each have their own recognition criteria and processes.
Bupa, which describes itself as the UK's leading health insurer with 2.4 million customers, requires consultants to be on the GMC Specialist Register in a recognised specialty, hold a substantive consultant appointment in the NHS or equivalent, hold current indemnity insurance, have practising privileges at a Bupa-recognised hospital, and submit all invoices electronically. Recognition is applied for online and Bupa states the process can typically be completed in under an hour. Recognised consultants are listed on Bupa's Finder directory, which Bupa reports receives over 100,000 visits per week from customers, GPs, and the public. This makes completing your Bupa profile a meaningful visibility exercise as well as an administrative requirement.
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AXA Health (a trading name of AXA PPP healthcare Limited) requires similar criteria: GMC Specialist Register listing in a recognised specialty, a substantive consultant appointment in the NHS or armed forces (or evidence of a previously held appointment for those working solely privately), current indemnity insurance, practising privileges at an AXA Health-recognised facility, and electronic invoice submission via Healthcode or an equivalent system.
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Other significant insurers including Aviva, Vitality Health, WPA, Cigna, and Simplyhealth also operate their own recognition and fee schedule systems. Building a sustainable insured patient caseload means identifying which insurers your target patient population is most likely to hold, and applying for recognition with those insurers in priority order rather than attempting to join all simultaneously.
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Bupa consultant recognition: bupa.co.uk: Consultant recognition
AXA Health provider recognition: provider.axahealth.co.uk: Individual Provider Recognition
Fee schedules and the insured fee structure
When you become recognised by a PMI, you agree to charge within that insurer's fee schedule for consultations and procedures. Each procedure has a corresponding CCSD code, and the insurer's schedule sets out the maximum amount it will pay for each code. If you charge above that maximum, the difference, known as a shortfall, falls to the patient. Persistent shortfalls lead to patient complaints and, in serious cases, can result in an insurer reviewing or withdrawing a consultant's recognition.
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CCSD stands for Clinical Coding and Schedule Development. CCSD codes are the standardised alphanumeric procedure codes used by all major UK private health insurers, including Bupa, AXA Health, Aviva, and Vitality Health. The CCSD Board includes representatives from these major insurers alongside representatives from private hospital groups and sector organisations. The schedule contains over 2,000 codes covering virtually all procedures performed in private practice, organised into 19 chapters by anatomical site or treatment type. The code W8500, for example, describes a multiple arthroscopic operation on the knee.
Using an incorrect code causes delays, claim rejections, or payment at the wrong rate. Aviva's guidance for consultants is explicit: coding accurately and appropriately is the consultant's responsibility, and if a procedure does not have a CCSD code, the consultant should contact CCSD to request one rather than using an approximation. TouchPoints.health is set-up to remove much of the complexity surrounding coding and simplifies the billing process greatly, ask our team on your demo call.
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Since April 2024, PHIN has also been collecting information about fee arrangements between consultants and PMIs, which appears on consultant profiles alongside self-pay fee data. This is part of the CMA's ongoing push for fee transparency across both payment types.
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CCSD schedule information: ccsd.org.uk
Aviva consultant guidelines: aviva.co.uk: How to use Aviva guidelines
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Billing insured patients through Healthcode
Healthcode is the official UK clearing organisation for private medical billing. It operates as the electronic intermediary between consultants and insurers, transmitting invoices and returning remittance advice. Healthcode reports processing around £2.5 billion of medical invoices annually, covering clinical records for virtually every private patient in the UK.
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Submitting through Healthcode offers genuine operational advantages beyond compliance. Claims are pre-validated against insurer requirements before submission, which means errors are caught before a claim leaves the practice rather than after it has been rejected by the insurer. Payment typically arrives faster than for manually submitted paper invoices. Remittance advice returns electronically, confirming whether claims were accepted, partially paid, or rejected with specific reason codes.
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TouchPoints.health integrates directly with Healthcode and makes this process considerably more efficient. A well-integrated system allows the clinical record, the correct CCSD codes, patient insurance details, and the submitted invoice to flow from the same source, reducing transcription errors and the administrative overhead of maintaining separate billing records. For practices with meaningful insured patient volumes, this integration is one of the highest-value administrative investments available.
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Healthcode: healthcode.co.uk
What your insured patients expect from the administrative process
Insured patients have often paid significant premiums for a degree of convenience and certainty, and their expectations of the administrative side of their care reflect that. The most common sources of dissatisfaction are unexpected shortfalls, lack of clarity about what is covered before treatment begins, and delays in receiving correspondence or invoices.
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Your practice can address most of these proactively. Before a procedure, verify with the insurer what has been authorised and at what amount. If your fee is higher than the insurer's schedule maximum, tell the patient in advance and in writing so they can make an informed decision rather than being surprised by a shortfall invoice after the fact. Keep the patient's pre-authorisation code on record and include it on every invoice to the insurer. Send any patient-facing correspondence promptly: a delay in receiving a post-appointment letter from the consultant is one of the most frequently cited frustrations among privately insured patients.
The Self-Pay Patient Pathway: A Different Set of Requirements
Self-pay patients are, in one sense, simpler to manage than insured patients: there is no pre-authorisation process, no insurer fee schedule to comply with, and no third party involved in settling invoices. But this simplicity creates its own responsibilities, particularly around fee transparency, payment terms, and debt management.
Setting your self-pay fees
Self-pay consultants set their own fees. There is no regulatory body that determines what you should charge, and since 2014 the BMA has not published recommended fee schedules due to competition law constraints. Your fees are a commercial decision based on your specialty, your experience, your location, your costs, and what the local market will bear.
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One critical legal constraint deserves direct attention: you must not jointly align your fees with fellow consultants. In July 2020, the CMA found that seven ophthalmology consultants had entered into an illegal "price-fixing agreement", having collectively agreed via email to charge self-pay patients the same initial consultation fee of £200 at a particular hospital. The CMA treated this as an agreement between competitors to restrict price competition, regardless of the rationale offered. The CMA's published case study on this enforcement action is essential reading for any consultant tempted to discuss fee levels with colleagues at the same hospital or in the same specialty group.
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Your fees must be set independently, reviewed regularly, and disclosed clearly to patients before they commit to treatment. PHIN has a legal mandate to collect and publish self-pay fee information from consultants, and Good Medical Practice 2024 references the obligation to submit this information. PHIN allows consultants to submit a range rather than a single fixed fee to account for the natural variation between cases.
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CMA case study on price-fixing in private healthcare: gov.uk: CMA case study
PHIN self-pay fee guidance: phin.org.uk: Self-funding your private treatment
Fee transparency obligations
PHIN describes the current transparency requirement clearly: the amount a patient is paying for private treatment out of their own pocket should be clear from the outset so they can properly assess their financial options. After a consultation, consultants are legally required to send a letter setting out their fees for any additional diagnostic tests and treatment. This is not optional and it is not at the consultant's discretion.
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Self-pay patients can choose between two payment structures. A package price bundles together the consultant's fees, hospital care, and often follow-up appointments into a single amount, which gives patients certainty about cost. A pay-per-service structure invoices each element separately, which reflects the actual complexity of care but requires more careful explanation upfront so patients understand what is and is not included in each invoice they receive.
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PHIN also maintains a consultant fee calculator on its public website, built from fee data submitted by consultants, which patients can use before booking to get a sense of what they are likely to pay. This means your published fee data on PHIN is an active part of how prospective self-pay patients assess whether to approach you. Keeping this data current and accurate is both a compliance obligation and a commercial consideration.
Payment terms and collections for self-pay patients
Unlike insured patients, where the insurer settles invoices directly, self-pay patients pay you or your practice directly. This creates a cash flow dynamic and a debt management responsibility that does not exist with insured work.
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Best practice for self-pay billing involves collecting payment, or at minimum a deposit, before elective procedures and at the time of each outpatient consultation. Taking card details at the point of booking, and being transparent with patients that payment is expected at the time of the appointment, reduces the risk of outstanding invoices accumulating. For procedures, confirming costs in writing in advance and collecting payment before the procedure date eliminates the most common source of post-procedure billing disputes.
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Your practice terms and conditions should set out clearly when payment is expected, what happens if a patient does not attend without adequate notice, and how any additional costs beyond the initial estimate will be communicated and invoiced. A written payment policy, provided to self-pay patients at the outset, protects both parties and makes it much easier to pursue outstanding amounts if they arise.
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Many private hospitals offer a package price framework that bundles their facility fees with consultant fees. Whether you participate in this is a commercial decision. Some consultants prefer to invoice separately from the hospital, giving them direct control over their fee income. Others find the administrative simplicity of a single package price, with payment managed by the hospital, preferable. Either model can work; what matters is that the patient understands clearly who they are paying and what they are paying for before any treatment begins.
Managing Both in Practice: The Administrative Differences That Matter
The challenge for most practices is not understanding either model in isolation but managing both simultaneously without constant manual effort and without errors that create patient complaints or unpaid invoices.
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Patient type identification from first contact
The single most important administrative step is identifying, at the point of initial contact, whether a patient is insured or self-pay and, if insured, with which insurer and under what policy. This information determines the entire subsequent administrative pathway: whether pre-authorisation is required before booking, which fee schedule applies, how the invoice should be submitted, and what the patient's out-of-pocket liability is likely to be.
A booking process that collects this information consistently, for every new patient, before the appointment is confirmed, prevents the most damaging errors. Finding out after a consultation that a patient is insured but no pre-authorisation was obtained, or that they hold a policy with an insurer you are not recognised by, or that the specific treatment they need falls outside their policy cover, creates a situation that is difficult and uncomfortable for everyone involved. None of these outcomes are inevitable if the booking intake process is thorough.
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What to check for insured patients before their appointment
Before an insured patient's first appointment, your administrative team should confirm that a valid pre-authorisation code has been obtained from the insurer. They should check that the authorisation covers the type of appointment being booked, since an authorisation for an outpatient consultation does not automatically extend to subsequent investigations or procedures. They should confirm that your practice is recognised by the patient's insurer, and that the hospital where the patient will be seen is also recognised under the patient's policy.
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For any procedure that follows an initial consultation, a fresh authorisation from the insurer is typically required. Building this step into your practice's workflow, rather than leaving it to the patient to manage, protects against uncovered treatments and ensures your invoices are submitted against valid authorisations.
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If you are treating a Bupa patient under their Open Referral scheme, the dynamics are slightly different. Under Open Referral, Bupa assigns the patient to a consultant from their fee-assured network rather than the patient selecting a named consultant independently. Bupa has developed this model partly in response to employer demand for predictable healthcare costs, and it is now offered across a significant portion of their corporate business. Being on the Open Referral network provides access to this patient population but requires accepting Bupa's fee schedule without shortfall charging.
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What to check for self-pay patients before their appointment
For self-pay patients, the equivalent pre-appointment checks are about fee communication and payment confirmation rather than authorisation. Confirm that the patient has received a clear written statement of the consultation fee before they attend. If a procedure is being booked directly, confirm that the patient has received and acknowledged the estimated procedure costs, including any elements billed separately such as anaesthetist fees, hospital facility charges, and implant costs where applicable. Establish how payment will be made and collect any deposit or card details required by your practice terms.
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A self-pay patient who arrives for a procedure without a clear understanding of what they will be asked to pay is a dissatisfied patient before the clinical encounter has even begun. The administrative investment in clear upfront communication pays for itself many times over in reduced complaints and disputes.
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The billing workflow after the appointment
For insured patients, invoices should be submitted to the insurer via Healthcode or directly via the insurers own portal as promptly as possible after the appointment. Most insurers have invoice submission windows, typically six months from the date of treatment, but submitting promptly accelerates payment and reduces the risk of queries arising from delayed submission. Ensure the correct CCSD codes are applied to every invoice. Include the patient's pre-authorisation code and membership number. If the insurer returns a rejection or partial payment, address the query promptly rather than allowing it to age. TouchPoints.health validates these fields before submission significantly reducing the risk of having a claim rejected.
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For self-pay patients, invoices should be issued promptly and in accordance with the payment terms established at the outset. Where payment is expected at the time of the appointment, the invoice should be presented and settled at that visit. Where payment is to follow, invoices should be issued within a short, defined timeframe, typically within a few days of the appointment. Outstanding invoices that are not followed up promptly become progressively harder to collect.
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Handling crossover situations
Two situations arise regularly that require careful handling at the intersection of insured and self-pay.
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The first is the patient whose insurer declines to authorise part of a treatment episode. If an insurer refuses authorisation for a diagnostic investigation your clinical judgement says is necessary, or if authorisation is granted for some procedures but not others, the patient may wish to proceed with the uncovered element on a self-pay basis. This needs to be handled with complete clarity: the patient must understand in advance which elements will be submitted to the insurer, which will be billed to them directly, and at what cost. A separate self-pay invoice for uncovered elements, clearly distinguished from the insurer submission, is the correct approach.
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The second is the patient who transitions from self-pay to insured or vice versa part-way through a treatment episode. This can happen if a patient takes out a new PMI policy during ongoing treatment, or if their insurer declines to continue authorising treatment for a condition that has become chronic. Again, clear written communication with the patient about what changes and what does not is essential. Insured patients should always be told if you expect them to have any out-of-pocket liability, whether an excess, a shortfall, or a cost for an uncovered element, before they incur it.
The Role of Practice Management Software in Handling Both Patient Types
Managing insured and self-pay patients in parallel, with their different administrative requirements, different billing routes, and different payment timelines, is significantly easier with practice management software that is designed for UK private practice and integrates with Healthcode like TouchPoints.health.
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TouchPoints.health applies codes from within the same interface used to record clinical notes, submits invoices directly to Healthcode, and tracks payment status for both insured claims and self-pay invoices in one place thus reduces the administrative burden considerably and, more importantly, reduces the scope for errors that cause delayed or missed payments.
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The value becomes most visible in the billing cycle. Without integration, generating an insured invoice means extracting patient and authorisation details from one system, applying CCSD codes from a reference document, creating an invoice in a separate billing tool, submitting it through Healthcode, and then tracking the response manually. With integration, most of that process is automated from the existing clinical record. The same logic applies to self-pay invoicing: practice management software that generates fee-quoted invoices automatically, tracks payment receipt, and flags outstanding items for follow-up gives the practice considerably better visibility of its financial position without requiring a dedicated billing administrator.
Common Administrative Errors and How to Avoid Them
Across both patient types, certain administrative errors recur with enough regularity that they are worth naming directly.
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For insured patients, the most damaging errors are treating a patient before pre-authorisation has been confirmed; submitting an invoice with an incorrect or mismatched CCSD code; failing to obtain separate authorisation for procedures that follow an initial consultation; charging above an insurer's schedule maximum without informing the patient in advance that a shortfall will arise; and submitting invoices late, outside the insurer's claims window. Each of these creates either an unpaid invoice, a patient complaint, or both.
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For self-pay patients, the most common errors are failing to confirm and document fee information in writing before the appointment or procedure; not collecting payment at the time of the consultation; issuing invoices late or inconsistently; and failing to follow up overdue invoices promptly. Unlike an insurer, where a claim query has a formal process and a known resolution pathway, an overdue self-pay invoice from a patient who has already received their treatment and moved on is difficult and sometimes unpleasant to pursue.
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The underlying cause of most of these errors is the same: administrative processes that rely on individual staff remembering what needs to happen next, rather than systems that prompt or automate the required steps. Building checklists and workflows for both patient types, whether within your practice management software or as documented procedures for your medical secretary, converts a dependency on individual memory into a reliable process.
A Note on Medico-Legal and International Patients
Some practices also see medico-legal patients, whose fees are paid by solicitors or their clients as part of legal proceedings, and international patients, who may hold international health insurance policies with different pre-authorisation and billing requirements. These payment types sit outside the insured and self-pay framework described here and require their own administrative approaches. If your practice sees significant volumes of either, they warrant separate process documentation.
Summary: The Practical Priorities
A practice that manages insured and self-pay patients well does not need a large administrative team. It needs clear processes applied consistently from the point of first contact.
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For insured patients, the priorities are: hold recognition with the relevant insurers; confirm pre-authorisation before every appointment and every procedure; use correct CCSD codes on every invoice; submit through Healthcode promptly; and communicate any shortfall risk to the patient in advance and in writing.
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For self-pay patients, the priorities are: set your own fees independently and review them regularly; publish your fees on PHIN as required; give patients written fee information before every appointment and procedure; collect payment promptly in line with your stated terms; and follow up outstanding invoices without delay.
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For both, a practice management system like TouchPoints.health that integrates with Healthcode, supports CCSD coding, and tracks both insured claims and self-pay invoices in one place reduces administrative overhead, reduces the scope for errors, and gives you the practice visibility you need to manage cash flow and patient relationships effectively.