Medical treatment

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The medical treatment includes all activities of the physician for the prevention, early detection and treatment of diseases . In many countries, medical treatment is a social security benefit .

Medical treatment in Germany

In Germany, the majority of medical treatments are part of the catalog of benefits of the statutory health insurance (GKV); the legal entitlement to this is anchored in Section 28 (1) SGB ​​V. People who are not insured by the statutory health insurance usually appear as private patients (self-payers) at the doctor's office. You almost always have contracts with private health insurers , the subject of which is the reimbursement of medical treatment costs. Eligible beneficiaries are also entitled to benefits. In the statutory accident insurance , medical treatment is also part of the catalog of benefits. Medical treatment also includes the services of other people, e.g. B. Employees of the doctor, if their activity can be delegated and is ordered and monitored by the responsible doctor.

Basically, in Germany there is free choice of doctor , whereby for patients with statutory health insurance, the doctor's approval as a contract doctor is a prerequisite for performance. If this is the case, medical treatment can be claimed in kind using the electronic health card (eGK). The services that the doctor has provided for his patient are then settled with the responsible health insurance company via the Association of Statutory Health Insurance Physicians. Benefits that go beyond the GKV's catalog of benefits can be used privately by the legally insured after a written agreement. These include, for example, so-called individual health services (IGEL).

Scope of services

The content of statutory medical care is stipulated by law in Section 73 (2) SGB V.

More details on the content of the statutory medical services are contractually regulated between the health insurance companies and associations of statutory health insurance physicians or decided by the joint federal committee .

Free choice of medical doctors

For the first time in Germany, the free choice of doctor was implemented in Stuttgart at the beginning of the 20th century. The driving force was Oskar Königshöfer .

Free choice of doctor means that the patient can generally turn to a freely chosen doctor of their choice for treatment. However, the law provides a framework of doctors and medical facilities from which the insured can choose. These are essentially:

Doctors who do not belong to the aforementioned groups of people or institutions may only be used by those with statutory health insurance in strictly defined exceptional cases. Such a case would be e.g. B. if no contract doctor could be reached in an emergency.

In the case of the so-called total hospital admission contract, the patient's consent does not relate to the treatment of a specific doctor. Rather, in view of Section 613 of the German Civil Code (BGB), every doctor specified in the roster is authorized to provide therapeutic treatment.

In Germany, employers cannot tell employees which doctor to go to if they are unable to work; The Labor Court of Frankfurt am Main declared a corresponding clause in the employment contract to be ineffective in 2011. For prescribed examinations, the free choice of doctor is restricted to the extent that preventive medical examinations require medical knowledge of the doctor ( occupational medicine / company medicine ) and, if necessary, further specialist knowledge. The employer must provide the examining doctor with the necessary information about the workplace and the result of the risk assessment and enable him to inspect the workplace. In a specific case, the Higher Administrative Court of Rhineland-Palatinate ruled on October 29, 2013 that an official from the professional fire brigade was not entitled to have a mandatory examination carried out by a doctor of his choice instead of the company medical service (not even at his own expense) ), although he had the qualification according to § 7 ArbMedVV. The court took into account the principle of proportionality and the consideration that "the free choice of doctor for regular compulsory examinations [...] would practically be associated with hardly manageable administrative costs". There is a constitutionally justified encroachment on the general right of personality.

In the case of the company medical service , the employer decides which doctor should treat the patient (employee). The free choice of doctor is therefore suspended here.

Transfers

German referral / settlement slip in the statutory health insurance

In the healthcare sector, a doctor refers to another doctor if he or she commissions certain services (e.g. X-ray or laboratory) (contract services), the professional opinion of a colleague (consultant examination), or if co-treatment (in the case of diseases other than the subject) or further treatment (when changing doctor) is necessary.

If there is such a reason, the doctor can refer his patient to another doctor using a specially provided form (referral slip). A referral slip is also used if the contract doctor arranges an outpatient operation in the hospital ( Section 115b SGB ​​V ) or an outpatient specialist medical treatment in the hospital ( Section 116b SGB ​​V ).

Like the insurance card, the referral slip is proof that the patient in question is eligible for benefits in kind under the statutory health insurance scheme . The referral slip is not required to settle the treatment with the Association of Statutory Health Insurance Physicians. Since the digitization of patient data, it is also sufficient to show the health insurance card as proof of insurance. A legal reason also exists in the free choice of doctor according to Section 76, Paragraph 1, Clause 1 of the Social Code Book V. The details are regulated in the federal contract for doctors.

In most cases, referrals are made by general practitioners to specialists . From 2004 to 2012, as an incentive for insured persons to only be referred to specialists by their family doctor, the legislature provided that no practice fee had to be paid to the specialist to whom the referral was made in one quarter . The practice fee was abolished with effect from January 1, 2013. Some health insurance companies also try to promote this so-called family doctor -centered care through special bonus models or family doctor models .

Ensuring medical care

In order to ensure adequate, appropriate, economical and necessary (dental) medical treatment for those with statutory health insurance, the legislature has assigned the so-called security order to the (dental) medical associations . The Association of Statutory Health Insurance Physicians conclude contracts with the health insurances regarding the modalities and remuneration, whereby the fifth book of the Social Security Code (SGB V) sets narrow limits for the contracting parties.

See also

Individual evidence

  1. For the discussion about the free choice of doctor in early health insurance cf. Collection of sources on the history of German social policy from 1867 to 1914 , III. Department: Development and differentiation of social policy since the beginning of the New Course (1890–1904), Volume 5, The statutory health insurance , edited by Wolfgang Ayaß , Florian Tennstedt and Heidi Winter, Darmstadt 2012.
  2. cf. BGH, judgment of May 11, 2010 , Az. VI ZR 252/08, full text.
  3. No restriction of the free choice of doctor by employment contract (Labor Court Frankfurt am Main, judgment of November 9, 2011 - 7 Ca 1549/11). rechtplus.de, accessed on March 23, 2014 .
  4. Guideline for company doctors on occupational health examinations. (PDF; 936 kB) (No longer available online.) German Statutory Accident Insurance (DGUV) Spitzenverband, November 2010, archived from the original on August 6, 2013 ; accessed on March 23, 2014 . 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. ISBN 978-3-88383-854-0 , ISBN 978-3-88383-855-7 , p. 10 @1@ 2Template: Webachiv / IABot / publications.dguv.de
  5. Az. 2 A 11256 / 12.OVG ( Memento of the original from July 12, 2014 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www3.mjv.rlp.de
  6. Official, tel. Information from the DAK
  7. § 76 SGB V Free choice of doctor. Retrieved July 8, 2019 .
  8. in particular §§ 24 , 13 paragraph 4 BMV-Ä; also samples 6 and 10 for the form agreement