Can patients pay for private GP appointments with insurance?

Why insurance rarely pays for GP appointments

UK private medical insurance (PMI) is built mainly around specialist and hospital care: outpatient consultations, diagnostics and inpatient treatment. Primary care has traditionally been left to the NHS. So when a patient asks whether their insurance covers your appointment, the honest default answer is “probably not, but check your policy”.

Insurers have added GP access in other ways, and these are what patients usually mean when they say their policy “includes a GP”.

The kinds of cover patients may have

Cover	What it usually means for you
Remote GP service included with the policy	Phone or video appointments with the insurer’s own partner service. It does not pay an independent private GP.
Face-to-face GP benefit in the insurer’s own clinics	For example, Bupa personal health insurance includes 15-minute face-to-face GP appointments at participating Bupa health centres. It does not apply to cover provided through an employer.
Private GP add-on that reimburses the patient	For example, AXA Health’s small business Private GP option reimburses up to £500 a year per person for private GP consultations, subject to its terms. The patient pays you and claims back.
Health cash plan	A separate product. The patient pays, then claims back some costs up to annual limits. Some plans include diagnostic consultations, so the patient should check their plan’s list.
International or overseas insurance, or embassy sponsorship	Some insurers will pay a provider directly, but only against a written guarantee of payment issued before treatment.

The details are at the time of review. Benefits change often, so point patients to their own policy documents rather than quoting cover yourself.

The usual model: pay you, then claim

For most insured patients the simplest arrangement is that they pay you in full at booking or on the day, then claim back from their insurer or cash plan if their cover allows. This keeps you out of the claims process and means you are paid on time. See collecting payment.

Make the claim easy for them. Give an itemised invoice or receipt showing:

• the patient’s name and date of the appointment
• your name, GMC number and practice details
• what was provided, with separate lines for the consultation, tests and any other items
• the amount paid and how.

Say clearly in your terms that the patient is responsible for your fee whether or not their insurer reimburses them.

Guarantees of payment

Some international insurers, travel insurers and embassies pay providers directly. They do so against a guarantee of payment (sometimes called a letter of guarantee): written confirmation that they will pay for specified care.

• Get it before the appointment. Without one, ask the patient to pay and claim back. Hospitals that bill insurers work the same way and take a deposit when authorisation is missing.
• Read the scope. Guarantees can exclude items such as reports, medicines or particular tests. Anything outside it is charged to the patient, so tell them before you provide it.
• Record it. Keep the guarantee with the patient’s record, with the authorisation or reference number, and invoice the insurer in the format they ask for.
• Agree who pays a shortfall. Make it clear the patient is liable for anything the insurer does not pay.

Insurance and onward referrals

Where insurance matters most for a private GP is the referral. Many PMI policies pay for specialist consultations and tests once the patient has a GP referral, and insurers generally expect the patient to get pre-authorisation before they book.

• Ask insured patients to call their insurer before you refer. The insurer may have a list of specialists or hospitals it will pay for.
• Ask them to check that the insurer accepts a referral from a private GP, and whether an open referral is needed.
• Tell them that tests you arrange and bill yourself are unlikely to be covered by their policy unless the insurer confirms otherwise.

See finding local private consultants for building a referral list.

Employers as payers

Some employers pay for private GP access for staff directly, outside insurance. That is a business contract between you and the employer. Agree what is covered, how and when you invoice, and how you keep clinical information confidential from the employer. See how to find patients.

What this means for your plan

Build your fees and cash flow on self-paying patients. Treat insurance reimbursement as something that helps the patient, not a source of income you can rely on. If you plan to see many overseas or embassy-sponsored patients, set up a written process for guarantees of payment and bad debt before you start.

Whatever the payer, the GMC expects you to be clear with patients about what they will pay for each investigation or treatment, and when. See how much to charge and managing patient expectations.