One appointment, three keyings #
A private appointment generates three separate records of the same event.
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The clinical note
Says what happened.
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The claim
Says what happened in the insurer's vocabulary, with their codes, their authorisation reference and their form.
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The invoice
Says what happened in money.
In most clinics those are three systems, three people and three moments, and nothing checks that they agree.
That is why the failures arrive late and expensively. A code that does not match the note, a procedure that was authorised for a different date, a patient whose policy details changed between booking and attending: none of those is discovered when it happens. It is discovered when the insurer declines, six weeks later, by which point the patient has gone home believing they owe nothing.
This is not a clinic specific disease. Duplicate entry between systems is the most consistent complaint we found across every sector on this site, in industries that have nothing else in common.
What you are required to tell patients #
Fee transparency in private healthcare is not a courtesy, it is a remedy imposed after a competition investigation. The Competition and Markets Authority published the Private Healthcare Market Investigation Order 2014 on 1 October 2014, under the Enterprise Act 2002, after concluding that the lack of publicly available performance and fee information on consultants harmed competition.
Article 22 requires consultants to give private patients specified information about their fees before an outpatient consultation or treatment, and to supply the Private Healthcare Information Network with their consultation fees and standard terms.
Dentistry has its own version through the General Dental Council's Standards for the Dental Team.
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A treatment plan 2.3.7
Requires a treatment plan containing a realistic indication of the cost and a statement of whether treatment is NHS or private.
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A price list in reception 2.4.1
Requires a simple price list clearly displayed in reception.
Both of those are administrative obligations attached to a clinical encounter, which means they can be missed quietly.
The shortfall, which is the part nobody plans for #
A claim settled short is the worst kind of debt a clinic carries, because it converts a business to business relationship into a conversation with a patient who thought they were covered. The clinic did the work, the insurer paid part of it, and the balance now has to be explained to somebody who is not expecting a bill.
There is a legal asymmetry here worth knowing. GOV.UK states that you can claim interest and debt recovery costs when another business is late paying for goods or a service. An insurer sitting on a claim is a business, so that applies. A patient with an outstanding balance is not, so it does not.
When the law treats a commercial payment as late
Where no payment date has been agreed, GOV.UK states that the law treats payment as late 30 days after the customer receives the invoice or the service is provided.
The two debts look identical on your aged debtors report and behave completely differently.
Which parts run on rules #
| The check | What it needs | Candidate? |
|---|---|---|
| An appointment attended with no claim raised | Diary and claims list | Yes |
| A claim submitted with nothing back after a set period | A submission date | Yes |
| A claim settled short with no shortfall raised to the patient | Amount claimed against amount received | Yes, it is arithmetic |
| An authorisation that expires before the booked date | Two dates | Yes |
| A patient balance untouched since the appointment | Ledger dates | Yes |
| Whether to write off a disputed balance | Judgement about a person and a relationship | No |
| Whether a rejected claim should be appealed | Clinical and commercial judgement | No |
Notice that every row in the yes column is a comparison between two things the practice already holds. That is what rule based means here, and the general test is set out on AI automation, explained. Notice too that none of the yes rows involves reading a clinical note or deciding anything about a patient's care.
Which parts do not #
Coding a procedure is a clinical judgement expressed in an insurer's language, and it belongs to the clinician. Four more sit with the practice.
- Whether to appeal a rejection.
- Whether to waive a shortfall.
- Whether to keep treating somebody who owes you money.
- How firmly to chase a patient who is unwell.
All of those are decisions about people, and none of them gets better by being made faster.
The data protection line #
Claims data is clinical data wearing a finance jacket. A procedure code attached to a named person is information about their health, which makes it special category data under UK GDPR, and your practice stays the controller for it whichever billing supplier or intermediary handles it. The patient data page points at the ICO's guidance on that rather than paraphrasing it.
What to look at first #
Two counts from your own system. How many attended appointments in the last quarter have no matching claim or invoice, and how many claims are older than your own expected settlement period with nothing received.
The first number tells you whether the keying is being missed. The second tells you whether anybody is watching the ones that were not missed. The chasing payment tool works from your figures, and cancellations and rebooking covers the other end of the same diary.