Fee schedules explained: why your list price and the insurer's rate are different numbers

A fee schedule is the list of rates an insurer has agreed to pay you for each type of appointment. It is a separate number from the price on your own list, and the gap between the two lands on every invoice you send that insurer. That gap is not an error, so chasing it will not work. It is a rate to review.

The short version

• A fee schedule is the rate an insurer agreed to pay, per appointment type.
• Your list price and their rate are separate numbers, and they drift apart.
• A shortfall that repeats identically is a schedule difference, not a mistake.
• Nobody wins a schedule difference by chasing it. You review the rate instead.
• Keep your agreed rates and recognition paperwork somewhere you can actually find them.

What a fee schedule is, and why it stops matching your price list

When an insurer recognises you as a practitioner, the recognition comes with money attached. Somewhere in that process a rate gets set for an initial consultation and a rate gets set for a follow-up. That is your fee schedule with that insurer.

The important part is that the number is fixed by the agreement rather than by your price list. Say your follow-up is £60 for a self-funding patient and the agreed rate with a payer is lower. They pay their rate and consider the claim settled in full. From their side of the desk, nothing has gone wrong.

Four things cause most of the drift between the two numbers, and none of them are dramatic.

You put your prices up and they did not. Most clinics review self-pay prices every year or two. A rate agreed when you were first recognised can sit unchanged for far longer than that. Nothing is broken. The two numbers have simply stopped being the same one.

You added an appointment type with no line on the schedule. A longer first appointment, shockwave, acupuncture, a joint session with two clinicians. If there is no agreed rate for it, it gets billed under the nearest existing thing and paid at the nearest existing thing's rate.

Recognition sits with the practitioner, not the clinic. This one catches growing practices out. A new associate is usually a separate recognition with its own rate, and until that is in place their work may be paid differently or not covered at all.

There was never a schedule for that insurer. You see their members, you invoice them, something gets paid, and nobody ever actually agreed a rate. In eleven years at a clinic front desk I saw this more often than you would think, particularly with the smaller payers.

Where the schedule lives, and why nobody can find it

Establishing the rate is rarely the hard part. Finding the paperwork that proves it is where the evening goes.

It tends to be in one of four places: the recognition email sitting in somebody's inbox from three years ago, the insurer's own provider portal, a payer-specific price list inside your practice software, or Healthcode's Private Practice Register, where practitioners apply for recognition with multiple insurers and keep their practising details in one place. Healthcode lists over 56,500 registered practitioners and five private medical insurers among the register's users.

What I would do, and what I do for the clinics I work with, is build one document. One row per insurer per appointment type, with the agreed rate, the date it was agreed, and where the evidence lives. It is dull and it takes an afternoon. After that every remittance either matches the row or it does not, and the guessing stops. That sheet is usually the first thing I build when I take over a clinic's billing.

How the gap shows up on your invoices

The tell is repetition. A one-off underpayment is usually an excess, an exhausted benefit, a missing authorisation or a coding problem. A schedule difference is the same insurer, the same treatment and the same amount short, every single time. If you can predict the shortfall before you open the remittance, it is the schedule.

Whatever you reconcile in, the job is the same: match what was paid against what was invoiced, line by line, and give every gap a cause. Billing platforms help with the mechanics, and Healthcode describes letting practitioners record and reconcile payments and reallocate shortfalls against the right invoices. Assigning the causes still needs a person who knows what the agreed rate was supposed to be. I have written separately about the process for chasing the shortfalls worth chasing, and schedule differences are the ones that are not.

Can you invoice the patient for the difference?

Sometimes, and it depends entirely on what you agreed with that insurer. Some agreements allow a patient top-up and some do not, and the answer sits in your terms with that specific payer rather than in general practice. Read them before you send anything, because a top-up invoice that breaches your agreement is a worse problem than the shortfall was.

If you do bill the patient, the invoice has to stand on its own: what the treatment was, what the insurer paid, what is outstanding and why. gov.uk sets out what an invoice must include and what your payment terms actually mean. In my experience the awkwardness comes from surprise rather than from the amount, so that conversation belongs at the front desk before treatment starts, not in an email six weeks later.

Asking for a rate review

You can ask. It is a normal commercial request and it does not damage the relationship. What turns it into a conversation rather than an email that gets filed is having the numbers ready before you send it.

• How many of their members you treated in the last twelve months, and the total you invoiced them.
• Your current self-pay price, and the date you last changed it.
• The current agreed rate, the date it was set, and where it is documented.
• Anything that has changed on your side: new qualifications, longer appointments, extra clinicians, extended hours.

Be realistic about the timeline. Rate reviews get decided on the insurer's cycle rather than yours, and plenty of requests come back declined or unanswered. It is usually still worth asking, because the alternative is absorbing the same difference on every invoice indefinitely.

When to accept the number instead

Not every gap deserves a campaign. If a payer sends you four patients a year and their rate is a few pounds under your list price, the honest answer is to accept it and put the time somewhere with more in it.

The figure that decides it is annual, never per invoice. A £6 difference across 200 appointments a year is worth a conversation. The same £6 across eight appointments is not. Work the yearly number out once per insurer and it will tell you which two payers to actually go after.

Underneath all of it, a fee schedule difference is a pricing decision that got made by default, usually years ago, and has been quietly repeating on every invoice since. It is the least urgent thing on the list and often the most valuable, because fixing it once fixes every future claim rather than a single one. Write the rates down, work out what each gap costs you across a year, and take the two biggest to the insurer.