Starting a Private Orthopaedic Practice: A Practical Guide

You spent more than a decade learning to operate and probably no time learning to run a business. Starting a private orthopaedic practice makes you responsible for premises, staff, billing, regulatory compliance and cash flow, usually while you still hold a public appointment. Most of the failures are not clinical: overheads that outrun income, unclear fees that generate complaints, and referrers who stop calling. This guide covers the decisions in the order you face them, with the rules that apply in the UK, Australia and the United States. Contract terms for salaried posts are in negotiating your first consultant contract.

Choose a practice model

The first decision sets your financial risk for years.

Before joining a group, ask what share of receipts goes to the group, what it pays for, how decisions are made, what restrictive covenants apply when you leave, and whether the group's standards match yours. You inherit its reputation.

A "hub and spoke" pattern suits many surgeons once referrals grow: main rooms near your main operating hospital, with satellite sessions in growing areas or large general practices where local patients prefer to be seen. Satellites can take time to pay for themselves.

The regulatory foundations

Each system has its own rules for who may see private patients, what they must disclose and how they are paid. Get these right before the first patient.

United Kingdom

Registration with the CQC (England). Many consultants see private patients under practising privileges granted by an independent hospital, and the CQC treats practising privileges (opens in a new tab) as equivalent to employment by that provider. Where you run a service independently and the hospital acts only as landlord, you must register unless an exemption applies. The consulting-room exemption (opens in a new tab) is narrow: it does not cover treatment under anaesthesia or intravenous sedation, or treatment given anywhere other than a surgery or consulting room.

Fee transparency. The Competition and Markets Authority's Private Healthcare Market Investigation Order 2014 (opens in a new tab) requires consultants to supply the Private Healthcare Information Network (PHIN) with outpatient consultation fees, standard fees for the 50 procedures they perform most often, and standard terms. Article 22 also sets what patients must be told in writing:

• Before an outpatient consultation: the estimated cost, any financial interests you hold in the facilities and equipment used, the insurers that recognise you, a prompt to check their policy, and the PHIN website.
• Before further tests or treatment: the reason, an estimate of the cumulative consultant cost of the recommended pathway, and what the estimate excludes, such as care for unforeseeable complications.

The Order also prohibits hospital operators from offering referring clinicians incentives linked to the revenue from the patients they refer.

If you hold an NHS consultant post. The Code of Conduct for Private Practice (opens in a new tab) (England, 2004) requires that agreed NHS commitments take precedence over private work except in emergencies, that private commitments are not scheduled when you are rostered for the NHS, that you disclose regular private practice in job planning, and that NHS facilities and staff are used for private work only with your employer's prior agreement. Patients who move from private to NHS care join the NHS waiting list at the same point as if they had been seen in the NHS. Private practice is also part of your appraisal.

Indemnity. NHS indemnity does not cover private work, so you need cover from a defence organisation or insurer that matches your private scope. The GMC's indemnity guidance (opens in a new tab) explains the legal requirement; options are compared in choosing medical indemnity cover.

Australia

Provider numbers. Services Australia issues a Medicare provider number for each location where you practise, and benefits cannot be claimed at a location until its number is issued. Apply for every planned consulting room, satellite clinic and private hospital as soon as your specialist registration is confirmed; delays hold up billing and cash flow.

How in-hospital fees are paid. For in-hospital services to private patients, the Department of Health (opens in a new tab) explains that Medicare pays 75% of the MBS fee and the patient's insurer at least 25%. Insurers offer no gap and known gap arrangements: if you charge within the insurer's limits, the patient pays nothing or a capped amount. Charging above them leaves the patient with an out-of-pocket gap. Your billing policy, whether you use gap schemes or charge above them, shapes your practice volume and the patients you see.

Informed financial consent. The Medical Board of Australia's code of conduct expects fees to be explained in time for patients to decide whether to proceed. Give a written estimate covering surgeon, assistant, anaesthetist and hospital costs, with expected rebates, well before the operation. Avant's guide to informed financial consent (opens in a new tab) is a practical summary.

Advertising. Section 133 of the Health Practitioner Regulation National Law prohibits advertising a regulated health service using testimonials; Ahpra's advertising guidelines (opens in a new tab) explain what that covers, including patient reviews you republish on your own website or social media.

Business structure. Sole trader, company and service-entity arrangements carry different liability and tax consequences. Where a family trust or company employs your staff and holds the lease, the Australian Taxation Office's ruling TR 2006/2 (opens in a new tab) requires the service fees to be commercially realistic. The ATO's service entity guidance (opens in a new tab) accepts fees of up to 40% of gross practice fees for GPs, but says specialists generally cannot rely on that rate and need independent market evidence; "industry norms" are not enough. Take advice from an accountant and lawyer who act for medical practices, and avoid templates.

United States

Coding and payment. Payment under the Medicare Physician Fee Schedule is built from relative value units for work, practice expense and malpractice, each adjusted for geography and multiplied by a conversion factor. For 2026, CMS set two conversion factors (opens in a new tab): $33.4009** for most physicians and **$33.5675 for qualifying alternative payment model participants. Employed surgeons are often paid on work RVUs at a contracted rate per RVU, so compare offers on that rate and on the base salary together.

The global period. Major operations carry a 90-day global period that includes the day before surgery, the day of surgery and the 90 days after; routine postoperative visits within it are not billed separately. CMS rules use modifiers to identify work outside the package: 57 for the visit at which the decision for major surgery is made, 24 for an unrelated visit during the postoperative period, and 25 for a significant, separately identifiable visit on the same day as a minor procedure. National Correct Coding Initiative rules bundle procedures normally performed together: the NCCI policy manual (opens in a new tab) states that surgical arthroscopy includes diagnostic arthroscopy, which is not separately reportable at the same encounter.

Documentation drives the claim. The operative note must support every code billed. Vague notes lead to denials, and billing for work the record does not support exposes you to fraud investigations.

Ancillary services and surgery centres. Ownership of in-office imaging, physical therapy and ambulatory surgery centres is a major source of income in US orthopaedic groups, and it is tightly regulated. The physician self-referral (Stark) law and the Anti-Kickback Statute, summarised by the HHS Office of Inspector General (opens in a new tab), govern referrals to entities in which you have a financial interest. Take specialist healthcare legal advice before buying in.

Billing and cash flow

Whatever the system, income arrives weeks or months after the work. Plan for the gap.

• Fund the first months. Expect several months of fixed costs before receipts settle. Borrowing for a lavish fit-out adds to the pressure; patients notice parking, clean facilities and a surgeon who listens, not marble floors.
• Watch money owed. Review outstanding accounts monthly. Unpaid claims and patient balances become harder to collect the longer they sit, so somebody must work rejected claims promptly rather than resubmitting and hoping.
• Know your overhead. Track what share of receipts goes on rent, staff, systems, insurance and consumables. Staff is usually the largest item. Review it against comparable practices with your accountant rather than relying on rules of thumb.
• Protect business time. Set aside a regular half or full day each week for financial review, meetings with your practice manager, correspondence and visits to referrers.

Staff and systems

The practice manager is your most important appointment. An experienced manager who understands billing, insurer arrangements and employment law usually pays for themselves by reducing lost income and staff turnover. Ask candidates how they would handle a rejected batch of claims, or a patient angry about an unexpected anaesthetic bill.

Start lean. If you begin with a few sessions alongside a public post, a remote reception service that answers in your practice's name and books into your system can cover the first months until volume justifies a full-time receptionist.

Software. Choose cloud-based practice management software that lets you check lists and messages securely away from the rooms, with accounting software linked to your bank feeds. If you use AI dictation or ambient scribe tools, check data protection, consent and how the output is reviewed before letters go out.

Design for your patients. If you treat hip and knee arthritis, choose high, firm waiting-room chairs with armrests.

Building referrals

General practitioners, physiotherapists, podiatrists and sports physicians decide where many patients go. An old saying in private practice ranks the qualities that keep referrals coming as availability, affability and ability, in that order, because referrers assume competence and judge you on the rest.

• Be available. Answer calls from referrers. See urgent cases quickly. A six-week wait for a new appointment loses referrers faster than any clinical failing.
• Write letters that teach. A reply that sets out the diagnosis, the options discussed, the reason for the recommendation and the expected recovery shows a referrer you are safe and saves them a phone call. Send it promptly.
• Offer something useful. Short educational sessions for local practices, on topics such as when to refer an ACL injury or which knee pain needs imaging, build relationships better than brochures. Ask referrers which problems they find hardest to manage.
• Match your network to your subspecialty. A foot and ankle surgeon needs podiatrists; an arthroscopic knee surgeon needs sports physiotherapists.

Online presence. Patients will look you up. A clear, fast website with your subspecialties, a profile and an easy way to book is enough to start. Keep advertising within your regulator's rules: Ahpra's ban on testimonials in Australia, and, in the UK, the requirement in the GMC's Good medical practice (opens in a new tab) that anything you communicate publicly, including advertising, is accurate, not false or misleading, and does not exploit patients' vulnerability or lack of medical knowledge. Professional use of social media is covered in social media for surgeons.

Managing risk in private practice

Consent and fees together. Document the clinical consent discussion, including alternatives and what matters to the patient, as described in informed consent after Montgomery. Document the financial discussion just as carefully. Unexpected bills cause complaints that a clear written estimate would have prevented.

Records. If it is not documented, you cannot show it happened. Keep operative notes, consultation notes and fee estimates in the same system.

When something goes wrong. See the patient more often, explain plainly, and decide in advance how you will handle fees for treating your own complications. Patients who feel abandoned complain; patients who feel looked after usually do not.

Protect your income. Your ability to operate is your main asset. Consider income protection that pays if you cannot work as a surgeon, not merely if you cannot work at all, and read the definitions before you buy. In the US, check whether malpractice cover is claims-made or occurrence-based, and who pays for tail cover when you leave.

Business literacy matters in public practice too

Even surgeons who never open private rooms work inside a business. Theatre time, staffing, implants and beds are finite, and managers allocate them on cost and activity. A surgeon who understands where a service's costs and value sit, speaks enough of the budget-holder's language to make a case, and recognises the incentives a system creates, can protect services that matter to patients. The practical starting point is a well-made case for resources: see writing a business case for surgical equipment.

The first year

The first one to two years are the hardest. You are building a business, a team and a reputation, often while holding a public appointment, and the temptation is to accept every add-on patient and weekend list for fear of an empty waiting room. Some of that is necessary early, but schedule protected time from the start and review your workload every few months.

Find an experienced surgeon whose practice you would like to emulate and ask them directly about their worst business and staffing mistakes. Then plan the business with the same care you would bring to a complex revision: assess it, plan it, and check the result.