Schedule of fees for dentists

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Basic data
Title: Schedule of fees for dentists
Short title: Dentists fee schedule
Abbreviation: GOZ (until 1988: BuGO-Z)
Type: Federal Ordinance
Scope: Federal Republic of Germany
Legal matter: Professional law of the medical professions ,
special administrative law
References : 2123-5
Issued on: March 18, 1965
( BGBl. I p. 123 )
Entry into force on: April 1, 1965
Last change by: Announcement of July 2, 2012
( BAnz of July 2, 2012)
Effective date of the
last change: 		July 1, 2012
(Art. 3 Sentence 2 Amendment Ordinance
of December 5, 2011,
Federal Law Gazette I p. 2661, 2683 )
Please note the note on the applicable legal version.

The fee schedule for dentists ( GOZ ) regulates the remuneration of dental services. The legal basis for the enactment is Section 15 of the Dentistry Act (ZHG):

The Federal Government is empowered to regulate the fees for dental work in a fee schedule by means of an ordinance with the consent of the Federal Council. In this fee schedule, minimum and maximum rates for dental services are to be set. The legitimate interests of the dentists and those obliged to pay the fees must be taken into account.

The GOZ is binding for all dentists in Germany when setting fees, unless otherwise stipulated by federal law (§ 1 Paragraph 1 GOZ). This mainly applies to those contract dental services for those insured by statutory health insurances ( funded patients ), which are billed according to the assessment standard for dental services (BEMA) and not directly with the patient, but via the statutory health insurance association .

Dental services that are not included in the BEMA or that go beyond the guidelines and regulations of SGB ​​V will be invoiced to the statutory health insurance patient by the contract dentist in accordance with the GOZ.

Since around 90% of patients in Germany are legally insured, full billing according to the GOZ is only made in a minority of cases (10% are private patients , including around half of civil servants entitled to subsidies , their spouses and children).

Only purely private dentists who are not licensed by the health insurance fund and therefore do not participate in contract dental care only bill with private liquidations prepared in accordance with the regulations of the GOZ .

Medical services for private patients are billed according to the fee schedule for doctors (GOÄ).

history

The Federal Fee Regulations for Dentists (BUGO-Z) from 1965 replaced the Prussian Fee Regulations for Licensed Doctors and Dentists from September 1, 1924 (Preugo). The latter had already specified a fee framework specified in gold marks for medical and dental services , which can be found, for example, in item III (fees for dentists) 1a ("For advising the dental patient including the examination of the mouth and any written prescriptions in the dentist's apartment Days ") from 1 to 20 marks (i.e. by a factor of 20), for position III 10a (" removal of a single-rooted tooth or its root ") from 1.50 to 15 marks (factor 10) and for position 47b ( "For making a pin tooth with a root ring") 25 to 200 marks (factor 8).

In the GDR , the Preugo was in 1924 for the few outside of the public health (clinics) approved Dentists until its dissolution in 1990. In the Federal Republic was founded in 1965 based on the 1952 adopted Dentistry Act by the federal government with the consent of the Federal Council adopted a fee schedule for dentists (BUGO-Z), which replaced the Preugo. After a general part, it also contained a list of fees, which, however, only showed simple fees. Section 2 BUGO-Z stated: “The remuneration is based on one to six times the rates in the attached fee schedule, unless otherwise specified. Within this framework, the fees and compensations are to be determined at reasonable discretion, taking into account the special circumstances of the individual case, in particular the difficulty of the service, the time required, the financial and income situation of the payer and the local conditions. ”The fee range was now continuous from simple to sixfold.

The GOZ was enacted in 1987 as a new fee schedule to replace the BUGO-Z by the federal government with the consent of the Bundesrat. The BUGO-Z from 1965 was "- including the newly added service areas - on the basis of the [then] fee volume converted to the new GOZ at no cost. […] Overall, the new fee schedule should not lead to a change in the fee volume. ”Since then, there has been no point value adjustment and thus no inflation adjustment. In the course of the changeover to the euro (1.95583 DM = 1 euro), the amounts were converted to two cents and generally had to be rounded off. After many years of protests on the part of the dental profession, work on the revision of the GOZ began in 2005. In the meantime, new treatment methods have been used that were not yet described in the GOZ. The GOZ had to be adapted to the state of medical science.

The draft of the new version of the GOZ (working draft, amendment) submitted by the Ministry of Health at the beginning of 2007 was rejected by the German dental profession. They had commissioned their own working time studies and presented their "Fee Schedule for Dentists" (HOZ) as a counter-draft.

On October 27, 2008, the Federal Ministry of Health (BMG) presented the draft bill with the reasons for a new GOZ. However, the draft was not pursued by the grand coalition. After the federal elections in 2009, a working group consisting of the BMG, the German Dental Association and the Association of Private Health Insurance was set up to resume work on a GOZ reform. On March 24, 2011, the BMG again submitted a ministerial draft, which finally came into force on January 1, 2012.

GOZ 1988

The GOZ 1988 of October 22, 1987 was valid from January 1, 1988 to December 31, 2011. The point value, which is uniform for all federal states, has been 11 pfennigs since 1988. When the euro was introduced, it was converted to 5.62421 cents. In order to receive the fee for the individual service position, the number of points for the respective service position is multiplied by the point value and the increase factor (see below).

Price development

In relation to the base year 1988, there was a price increase of 61% in Germany from January 1988 to January 2012 - which corresponds to an average annual increase of 2.15% - while the GOZ fee has remained unchanged and has therefore been devalued every year since it came into force .

In contrast to the doctors and dentists, the fee schedules of other freelance professions (lawyers, notaries , architects , tax consultants ) have a certain automatism, which at least partially links them to the general price trend. The fees for these liberal professions are partly calculated depending on the market value of another object (lawyer: value in dispute, for example for a car or house; notary: purchase price of a property; architect: construction costs of a house; tax consultant: operating profit), which gradually increases along with general inflation . In these liberal professions the fees rise at least partially gradually with the general inflation even without a change in the fee structure, while the fees for doctors and dentists do not contain any such element.

The argument of price development, which is mainly put forward by dentists, is countered by the Ministry of Health, politics or private health insurance that the average income of a dentist is sufficient. The average figures presented are contested in their composition and interpretation by the dentists. In the case of the self-employed, the level of income is not comparable with the income of an employee.

The Association of Private Health Insurers also points out that the application of higher rates of increase has resulted in a noticeable increase in dental fees even without the GOZ reform. According to the PKV Association, dental treatment costs rose by 65 percent in the ten years before the GOZ came into force in 2012. The general price increase was only 17 percent in the same period.

GOZ 2012

On November 4, 2011, the Federal Council approved the amendment to the GOZ issued by the Federal Government for January 1, 2012. The GOZ 2012 came into force on January 1, 2012 ( BGBl. 2011 I p. 2661 ). As part of the update of the GOZ, numerous fee items were added and some fee items were omitted. The point value remained unchanged. According to calculations by the Federal Ministry of Health , this should increase the total fee volume by 5.8%. The current version of the GOZ has been heavily criticized by both dentists and the Association of Private Health Insurance. The dental profession has therefore lodged a constitutional complaint against the GOZ 2012.

The new GOZ received some changes in the paragraph part, for example

  • Obligation to agree in writing on demand services,
  • Concretizations in § 5 on the subject of the measurement of the increase factors,
  • the calculation of analog services in § 6 has been liberalized,
  • Obligation to submit a cost estimate for expected invoice sums over € 1,000,
  • Review of the effects of the GOZ in the new § 12.

Target performance principle

The target performance principle is a term from the private schedule of fees for doctors (GOÄ) or the private schedule of fees for dentists (GOZ), in which it was included with the amendment of the GOZ on January 1, 2012 and has the avoidance of double fees for medical services as of Target. In addition, it says in Section 4 (2) of the GOZ:

The dentist cannot charge a fee for a service that is part of or a special implementation of another service according to the schedule of fees if he charges a fee for the other service. This also applies to the individual operational steps that are methodically necessary to provide the operational services listed in the schedule of fees. A service is a methodologically necessary component of another service if its content is included in the service description of the other service (target service) and has also been taken into account in its evaluation.

Increase factor

To determine the amount of the fee, the fee rate is multiplied by an increase factor. “Fee rate” is the amount that arises when the number of points for the individual service in the list of fees is multiplied by the point value (Section 5 (1) sentence 2 GOZ).

The increase factor can be agreed in writing prior to the provision of the dentist's service in accordance with Section 2 Paragraphs 1 and 2 GOZ. If this has not happened, the dentist must determine the increase factor at his own discretion after the service has been fully provided. In this case, the dentist is bound by the fee framework defined in Section 5 (1) GOZ (one to three and a half times the fee rate).

§ 5 GOZ stipulates in 2012:

The amount of the individual fee is based on one to three and a half times the fee rate. […] Within the framework of fees, the fees are to be determined at reasonable discretion, taking into account the difficulty and the time required for the individual service as well as the circumstances during execution. The difficulty of the individual service can also be justified by the difficulty of the illness. Dimensioning criteria that have already been taken into account in the specification of services have to be disregarded. The 2.3-fold fee rate represents the average performance according to difficulty and time required; exceeding this fee rate is only permissible if special features of the assessment criteria specified in sentence 1 justify this; Services with a below-average level of difficulty or expenditure of time are to be charged at a lower fee rate.

Instead, the GOZ in 1988 found the following formulation of Section 5 (2):

As a rule, a fee may only be set between one and 2.3 times the fee rate; Exceeding 2.3 times the fee rate is only permitted if special features of the assessment criteria mentioned in sentence 1 justify this. [...]

In the past, this led to reimbursement problems with private health insurances, because they concluded from the phrase “As a rule” that an average medical service should be billed with an average value within the standard range (1 to 2.3 times). That is the 1.65-fold increase factor (at most the 1.8-fold factor). This also resulted in the concept of the maximum standard rate , which did not exist in the GOZ. In contrast, however, the Federal Court of Justice found in a ruling that, depending on the difficulty and time required, average services can be billed with a factor of 2.3.

No justification is required for an increase factor in the range from 1.0 to 2.3. If the dentist exceeds this factor, he must justify this in a comprehensible manner in writing. (Example: "increased expenditure of time and increased difficulty due to obstructed mouth opening").

Multiplying the simple rate by the 3.5-fold increase factor results in the highest possible rate that can be calculated according to § 5 GOZ, provided that no fee agreement according to § 2 GOZ was concluded before the start of treatment. In the case of an increase factor that is greater than the factor 2.3, the calculation must contain a justification for the selected multiplier, which justifies the particular degree of difficulty and time required as well as the circumstances of the execution. At the request of the patient, the dentist must provide an explanation of the reason for the increase factor of over 2.3 times.

Most private health insurance companies only reimburse up to a 2.3-fold or 3.5-fold increase factor. Usually, this reimbursement restriction of 3.5 times the rate is only not included in so-called old contracts.

The allowance for civil servants reimburses their beneficiaries only up to 2.3 times the rate and otherwise requests detailed justifications from the dentist.

Fee amount

The fee range 1 to 3.5 times the GOZ suggests that the simple rate of the fee schedule is the "normal" and a higher multiplier than the simple rate accordingly exceeds the "normal". This is transferred from the doctors' fee calculation according to the fee schedule for doctors (GOÄ), in which the simple rate roughly corresponds to the fee of the statutory health insurance funds (EBM) . The GOZ, on the other hand, is measured in such a way that in many cases 2.3 times the GOZ rate corresponds to the fee of the statutory health insurance companies according to the assessment standard for dental services (BEMA). In some cases, a fee exceeding the fee framework of § 5 GOZ (e.g. multiplier 4 to 6 times) corresponds to the cash desk fee. In the medical billing, the rate of 3.5 times the rate corresponds on average to 3.5 times the health insurance fee (increase of 250%), while in the dental billing the 3.5 times the rate on average is 1.5 times the Cash register fee (50% increase).

The GOZ analysis by the German Dental Association showed that the average multiplier applied for personally performed services by the dentist was 2.45 times the rate and for medical-technical services 1.96 times the rate. 65.4% of the benefits were liquidated at 2.3 times the rate, 7.9% of the benefits below 2.3 times the rate and 26.6% of the benefits above 2.3 times the rate.

example

This results in a single fee rate (single fee rate) of € 3.94 (number of points times point value; 70 × 5.62421 cents); or a 2.3-fold rate of € 9.06 and a 3.5-fold rate of € 13.79. Since the new GOZ came into force on January 1, 2012, certain material costs, for example for anesthetics, can be calculated in addition to the fee.

The health insurance fee for this service is between € 10.84 and € 11.45, depending on the health insurance company. (Sample calculation refers to the KZV area Westfalen-Lippe; as of January 1, 2012). In the area of statutory health insurance , all services are billed according to a fixed amount, regardless of the individual difficulty. The amounts may be subject to a degression . The example shows that with an increase factor of 2.3, private services are sometimes rewarded less than those with statutory health insurance patients.

On the other hand, there are also services that are better rewarded according to the GOZ private fee schedule than according to the BEMA.

For more examples, see Individual prophylaxis # private dentistry

Analog services

With the entry into force of the GOZ 2012, the dentist can charge independent dental services that are not included in the list of fees in accordance with Article 6, Paragraph 1 of the GOZ , according to a service of the list of fees that is equivalent in terms of type, cost and time expenditure .

The selected analog service must therefore be equivalent to the service not shown in the GOZ , not the same, i.e. not similar in content. The analog performance must reflect the corresponding reasonable monetary value of the performance not included.

Up to January 1, 2012, only services that were not described in the GOZ and that were only ready for practical use after the GOZ came into force, i.e. before January 1, 1988, were allowed to be calculated analogously (Section 6 (1) GOZ 1988). This restriction no longer applies with the 2012 amendment to the GOZ.

Billing of non-contractual dental services

Numerous treatments are not part of the contract dental care. These services are billed privately according to the fee schedule for dentists (GOZ) or according to the fee schedule for doctors (GOÄ). The costs are to be paid by the patient (or person liable to pay), who in turn can take out private supplementary health insurance . Services that do not belong to the catalog of services of the statutory health insurance companies are called non-contractual services . These must - after the patient has been informed about his entitlement to benefits in kind and the additional costs incurred - be agreed in writing with the patient before the start of treatment.

These include in particular:

  • All services that violate the economic efficiency requirement in accordance with Section 12, Paragraph 1 of Book V of the Social Code, i.e. that exceed the criteria for benefits in kind, as defined in Section 12, Paragraph 1 of Book V of the Social Code:

The services must be sufficient, appropriate and economical; they must not exceed what is necessary. Insured persons cannot claim services that are not necessary, service providers are not allowed to provide services and the health insurances are not allowed to approve them.

Additional cost agreements

In the following cases, co-payments by the legally insured patient are permitted. The prerequisite is the patient's written consent prior to the start of treatment.

Dental fillings

The additional cost agreement for filling therapy is regulated in § 28 SGB ​​V. There it says: “If insured persons choose additional care for dental fillings, they have to bear the additional costs themselves. In these cases, the health insurance companies must invoice the comparable, cheapest plastic filling as a contribution in kind. In the cases of sentence 2, a written agreement must be made between the dentist and the insured person before treatment begins. The additional cost regulation does not apply to cases in which intact plastic fillings are replaced. "

These include B. modern plastic fillings using the dentin-enamel adhesive process , gold inlays , ceramic inlays and the like. v. a.

dentures

Since the introduction of the fixed subsidy for dentures (until 2004 a percentage fund subsidy was paid), a distinction has been made in the supply of crowns and dentures between standard care , similar and different types of care. Standard care is billed according to the assessment standard of dental services (BEMA), for similar care, both the BEMA and the fee schedule for dentists (GOZ) are charged, and for other types of care, only the GOZ is used. The patient must bear the difference to the fixed allowance for standard care himself.

73c contracts

Some health insurance associations have concluded so-called collective quality contracts with individual health insurance companies in accordance with Section 73c SGB V, which apply to those insured in the federal state concerned. According to these contracts, insured persons can claim benefits that go beyond the service catalog or the economic efficiency requirement (see above) of the statutory health insurance . These services are billed to the patient in accordance with the schedule of fees for dentists, with the corresponding payment in kind, which is billed via the Association of Statutory Health Insurance Dentists, being deducted.

Base tariff

The statutory health insurance associations also have to ensure the care of those insured persons who are insured under the so-called basic tariff with a private health insurance company ( Section 75 Paragraph 3 a Clause 1 SGB V). Its contractual services should be comparable in type, scope and amount to the services according to the third chapter of the fifth book of the Social Security Code to which there is an entitlement ( Section 152 (1) sentence 1 VAG). The calculation of dental services is legally limited in the basic tariff to an increase factor of a maximum of 2.0 ( Section 75 (3a) sentence 2 SGB V). Something different was not agreed in contracts between the Association of Private Health Insurance and the Association of Statutory Health Insurance Physicians.

The contract dentists are not, however, directly from the statutory security order according to Section 75 (3a) sentence 1 SGB V obliges to treat insured persons in the basic tariff under the insurance conditions applicable there, because this statutory security mandate is not aimed directly at contract doctors and contract dentists, but rather at the statutory health insurance (dental) medical associations that are independent of their members as corporations under public law. It is up to the statutory health insurance associations to decide in which way they most appropriately fulfill this statutory mandate.

Insofar as a statutory health insurance association does not oblige its members to treat insured persons of the basic tariff, the contract dentists are free to choose whether to treat this group of insured persons. Only if the insured person proves to be insured in the basic tariff and the dentist then agrees to treatment under his / her conditions does the legally stipulated, remuneration-limiting increase factor of 2.0 apply to the dental services. Doctors therefore have the choice of either carrying out treatment at this reduced rate of increase or refusing such treatment. With regard to the type and scope of the treatment services, the GOZ remains the authoritative basis for calculation, because there is no different collective-legal written contract between the National Association of Statutory Health Insurance Physicians and the PKV Association within the meaning of Section 72 (2) SGB V.

Legal relationships

When treating a private patient who is billed according to the GOZ, there is a treatment contract between the dentist and the patient. There is therefore no legal relationship between the dentist and private health insurance.

Until the introduction of compulsory insurance (basic tariff), private patients could also be without health insurance and pay their dental bill as a self-payer. Since July 1, 2007, private health insurances have had to accept everyone wishing to join, but only in the standard or basic tariff.

In the event of a dispute with the dentist, patients often point out that the private health insurance does not recognize a certain benefit and therefore does not reimburse it or that the allowance only reimburses up to a certain increase factor. Even with payment deadlines, some patients point out that the reimbursement has not yet been received from the PKV.

As a secondary obligation under the treatment contract, the dentist has the duty to support the patient with the reimbursement. He should prepare a cost estimate for expensive treatments and encourage the patient to obtain a declaration of cost coverage from the private health insurance. It is not a duty of the dentist to have the insurance contract or the cost assumption declaration presented by the private health insurance company or to advise him on insurance law.

Privately insured person's right to information

Section 192 of the Insurance Contract Act (VVG) has been extended by a paragraph 8, which now legally regulates the claim to be issued a cost assumption declaration, developed by case law:

The policyholder can request information from the insurer in text form about the scope of the insurance cover for the intended therapeutic treatment before the start of treatment, the costs of which are expected to exceed EUR 2,000. If the treatment is urgent, the insurer has to provide a reasoned information immediately, at the latest after two weeks, otherwise after four weeks; a cost estimate submitted by the policyholder and other documents must be considered. The period begins when the insurer receives the request for information. If the information is not provided within the deadline, the insurer will assume that the intended medical treatment is necessary until proven otherwise.

Normally, the insured person has to prove to the insurer that medical treatment is necessary. If the deadline for a binding declaration of cost assumption was exceeded, the burden of proof would be reversed at the expense of the insurer in the event of a legal dispute, who would now have to prove that treatment was not medically necessary and that he therefore does not reimburse.

Sections of the GOZ

§ 1 Scope
§ 2 Deviating agreement
§ 3 Remuneration
§ 4 Fees
§ 5 Assessment of fees for services in the fee schedule
§ 6 Fees for other services
§ 7 Fees for inpatient treatment
§ 8 travel allowance
§ 9 Reimbursement of expenses for dental services
§ 10 Due date and settlement of the remuneration; invoice
§ 11 Transitional Provision
§ 12 review

Annex 1: List of fees for dental services: number, description of services, number of points, fee in euros - the simple rate is shown.

Annex 2: Liquidation form (formal requirements for the invoice)

Individual evidence

  1. ↑ Schedule of Fees for Dentists (GOZ) 2012 (PDF; 3.0 MB)
  2. ↑ Federal Fee Regulations for Dentists (BUGO-Z)
  3. ^ Prussian fee schedule for licensed doctors and dentists from September 1, 1924. HH Nölke Verlag, Hamburg 1946.
  4. ^ Fee schedule for dentists of March 18, 1965, Federal Law Gazette 1965, Part I, p. 123 ff.,
    Quoted from: Claus Peter Abée: Thoughts on the schedule of fees for dentists: a documentation . Quintessenz Verlag GmbH, Berlin, Chicago, London, São Paulo, Tokyo 1991, ISBN 3-87652-804-6 , pp. 31 .
  5. ↑ Official justification for the new GOZ, Bundesratsdrucksache 276/87, p. 58
    quoted from: Claus Peter Abée: Thoughts on the schedule of fees for dentists: a documentation . Quintessenz Verlag GmbH, Berlin, Chicago, London, São Paulo, Tokyo 1991, ISBN 3-87652-804-6 , pp. 136 .
  6. ↑ Referent draft for the new GOZ ( Memento of the original from June 28, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF; 2.7 MB), Federal Ministry of Health  @1@ 2Template: Webachiv / IABot / www.bzaek.de
  7. ↑ https://www.pkv.de/service/pkv_publik/archiv/2011/pkv-publik-nr-08-2011/sagen-sie-mal-ooh/
  8. ↑ Judgment of the BGH of November 8, 2007 AZ III ZR 54/07 (PDF; 96 kB)
  9. ↑ National Association of Statutory Health Insurance Dentists, Annual Report 2012, p. 67
  10. ↑ § 28 SGB ​​V exclusion of benefits
  11. ↑ § 73c SGB V
  12. ↑ BMG: basic tariff
  13. ↑ Non-acceptance decision of the BVerfG of May 5, 2008, 1 BvR 808/08
  14. ↑ Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 24; Sodan / Sodan: Handbook of Health Insurance Law, Section 45 No. 34
  15. ↑ Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 24
  16. ↑ BGH IV ZR 131/05 of February 8, 2006
  17. ↑ BGH IV ZR 213/91 of October 22, 1987
  18. ↑ Section 192 (8) VVG

literature

Web links