Uniform evaluation standard
The uniform evaluation standard (EBM) is the remuneration system for contract medical or contract psychotherapeutic care in Germany. It is a directory under social security law in the German health system , according to which outpatient and attending medical services are billed in the statutory health insurance .
Historical development
The EBM was introduced with the Health Insurance Cost Reduction Act (KVKG) of 1977. Up to this point in time, the individual types of insurance in the statutory health insurance ( AOK , BKK , substitute funds, etc.) had negotiated different fee schedules with the National Association of Statutory Health Insurance Physicians and the associations of statutory health insurance physicians . From the legislature's point of view, this made it more difficult for the then intended to restrict spending. Therefore, the legislature stipulated that from 1978 a “uniform” evaluation standard had to be used for all health insurance companies . Such a uniform assessment standard - called assessment standard for dental services (BEMA) - has also been prescribed for the dentist sector since then. The billing of services for private patients is based on the fee schedule for doctors (GOÄ), a statutory ordinance of the federal government .
Legal basis
The basis of the EBM is the fifth book of the Social Security Code (SGB V) . In § 87 Abs. 2 SGB V is set:
“The uniform evaluation standard determines the content of the billable services and their relative value, expressed in points; As far as possible, the services are to be provided with information on the time required by the contract doctor to provide the service. "
As of the EBM 2000plus , the framework structure of the current EBM is also specified by the GKV Modernization Act (GMG) that came into force on January 1, 2004 . What is new about this is that the services are to be summarized in complexes or flat-rate cases and that cooperative forms of care must be given special consideration.
Since April 1, 2014, the EBM 2014 has been the applicable fee schedule for the treatment of patients with statutory health insurance. It is continuously developed by the evaluation committee according to SGB V.
The EBM applies in principle - but not without exception - to the outpatient treatment of patients of the statutory health insurance (GKV). Billing takes place with the responsible Association of Statutory Health Insurance Physicians (KV) if the doctor is licensed as a contract doctor or authorized as a hospital doctor or - if he is not both - in emergency treatment. Services that are not included in the EBM cannot bill contract physicians or contract psychotherapists through their responsible KV at the expense of the GKV and must therefore be paid for directly by the patient according to the fee schedule for doctors (GOÄ) and fee schedule for psychotherapists (GOP). Hospital doctors can only be authorized if there is a supply gap in the offer of the registered contract doctors.
Authors / Contributors
The EBM is decided by the evaluation committee , which is composed equally of three representatives each from the central association of statutory health insurance (GKV-Spitzenverband) and the National Association of Statutory Health Insurance Physicians (KBV) . In the event of partial or total lack of quorum, the evaluation committee is expanded to include an impartial chairman and two other impartial members ( extended evaluation committee ). The health economist Jürgen Wasem ( University of Duisburg-Essen ) has been the chairman of the extended assessment committee since September 2007 .
Resolutions made by consensus in the evaluation committee or resolutions of the extended evaluation committee are binding. However, since the 2007 health reform , the Federal Ministry of Health has had the opportunity to object to resolutions. If legally prescribed resolutions are not passed, the ministry can carry out a substitute action; it can also call the Extended Evaluation Committee itself if neither side calls it - the ministry has not yet made use of this.
structure
Overview
The EBM is divided into six areas:
- General provisions
- Cross-doctoral general services
- Doctor group-specific services
- Cross-doctoral special services
- Flat rate fees
- Attachments
There are currently four appendices. Appendix 1 contains the list of services that are not separately billable and included in complexes, Appendix 2 defines the allocation of the operative procedures according to Section 301 SGB V to the services in Chapters 31 EBM (outpatient operations) and 36 EBM (attending medical operations), in Appendix 3 contains the information on the time required by the doctor to provide the service in accordance with Section 87 (2) sentence 1 of the Social Code Book V in conjunction with Section 106a (2) of the Book V of the Social Code and since July 2007 the services that are no longer billable or no longer billable are listed in Appendix 4 .
The parts in detail
Each billable service may have a. a number called the EBM number or fee schedule line item (GOP) and a score. Some of the EBM numbers have guide times that are required for plausibility checks after billing.
The general services for all doctors are open to all doctors. Here you will find services that are required for emergency service , “untimely” figures for services at night and on weekends, home visits , reports, pregnancy and substitution care and prevention services . All numbers in this part begin with the digits 01.
The part general diagnostic and therapeutic services includes smaller surgical services such as punctures , wound care , infusions , transfusions , plaster of paris and some physical therapies . The services in this chapter are also available to all medical specialist groups. The numbers of this part begin with the digits 02,
The part with the doctor group-specific services is the most detailed. The EBM numbers with the actual care services and specialist (doctor) -specific complexes are shown separately for general practitioners and all specialist groups (which also include psychological psychotherapists ). There is a separate chapter for each specialist group, the performance numbers begin with different numbers, e.g. for general practitioners with 03, paediatricians with 04, ophthalmologists with 06 and so on up to urologists (26) and specialists in physical and rehabilitation medicine (27). In this chapter, the respective specialists can only bill performance figures from "their" chapter.
The cross -group special services are again available to all doctors, however, approval from the relevant statutory health insurance association is required for billing . This is generally tied to certain qualifications. Service 30201 (chiropractic intervention ) can only be billed if the doctor has attended the relevant training . Outpatient or attending medical operations and laboratory and X-ray services are also dealt with in this part.
In part costs are miscellaneous operating cost packages are listed as postage , tolls during visits and certain consumables.
Vaccination services are not part of the EBM , as there are slightly different regulations in each federal state , which are not uniform within the various types of health insurance (e.g. primary or substitute insurance , miners' union).
Examples
Examples of such EBM numbers, their evaluation in points and amounts based on the EBM, as of July 1, 2013
- GOP 01410 home visit 600 points: 21.22 €
- GOP 01730 early cancer detection examination in women 510 points: 18.04 €
- GOP 03110 one-time general practitioner insurance lump sum per quarter for patients up to the 5th year of age. 1190 points: 42.08 €
- GOP 03111 one-time general practitioner lump sum per quarter for patients aged 5 to 59. 880 points: 31.12 €
- GOP 03112 one-time general practitioner insurance lump sum per quarter for patients aged 60 and over. 1020 points: 36.07 €
- GOP 03115 every further doctor-patient contact in the quarter (canceled since January 1, 2008), d. H. no remuneration for further GP services
- GOP 03321 Stress ECG 565 points: 19.98 €
- GOP 04110 one-time flat rate per quarter for children up to age 5. 1190 points: € 42.08
- GOP 05330 anesthesia or short anesthesia 2375 points: € 83.99
- GOP 26350 Small urological surgery 220 points: 7.78 €
The medical fee results from the number of points, multiplied by a regional point value , which, in accordance with Section 87a (2) SGB V , is to be agreed by the statutory health insurance associations and the regional associations of health insurance funds and the substitute funds on the basis of the orientation (point) value (see below) . Surcharges and discounts on the point value can also be agreed.
There is also a so-called imputed point value that is used to calculate the number of points for the various fee schedule items in relation to one another. For the EBM, which has been in effect since April 1, 2005, an imputed point value of 5.1129 cents (previously 10 pfennigs) applied until September 30, 2013; on October 1, 2013, the imputed value and the orientation point value were adjusted to a value of 10 cents. Since the evaluation of the fee schedule items was reduced in points at the same time, this adjustment did not result in any change in the fee amount in euros, apart from rounding differences.
Examples:
| EBM as of July 1, 2013 | EBM as of October 1, 2013 | |||||
|---|---|---|---|---|---|---|
| GOP | Points | amount | Points | amount | ||
| 01410 | 600 | € 21.22 | 212 | € 21.20 | ||
| 03321 | 565 | € 19.98 | 200 | € 20.00 | ||
| 05330 | 2375 | € 83.99 | 840 | € 84.00 | ||
Fee distribution
The scores determine the value relationship between the services. For example, a doctor receives twice as much money for a service rated at 100 points as for one rated at 50 points.
| year | Remuneration per point |
|---|---|
| 2020 | € 0.109871 |
| 2019 | € 0.108226 |
| 2018 | € 0.106543 |
| 2017 | € 0.105300 |
| 2016 | € 0.104361 |
| 2015 | € 0.102718 |
| 2014 | € 0.101300 |
| 2013 (4th quarter) | € 0.100000 |
| 2013 (1st - 3rd quarter) | € 0.035363 |
| 2012 | € 0.035048 |
| 2011 | € 0.035048 |
| 2010 | € 0.035048 |
| 2009 | € 0.035001 |
| 2008 | € 0.033600 |
However, each point does not always correspond to the same cent value. How much a point is worth can only be said once the average point value in the accounting period has been determined. This results from the amount of money made available by all statutory health insurance companies in a region and the total number of points for all outpatient medical services for patients in the region who are insured with the health insurance companies according to EBM. In 1998, the average point value for all statutory health insurances in Germany was 3.72 cents. The EBM is therefore not a “price list” for the health insurance companies (such as the fee schedule for doctors , which is used for private patients), but mostly only regulates the distribution of the previously determined total fee volume to the various doctors. Only in the case of so-called "extra-budgetary" services (e.g. certain preventive services, outpatient surgery) is the doctor reimbursed at full price in any case, which the health insurance companies reimburse the Association of Statutory Health Insurance Physicians without applying any quantity-limiting regulations.
The points that can be billed to the KV by a doctor have been capped since the mid-nineties of the 20th century via the so-called practice budgets , which were set by the KV for each practice. Points (i.e. services) that are billed beyond the practice budget were not reimbursed.
With the Statutory Health Insurance Modernization Act , from 2004 to 2011, so-called standard benefit volumes were applied instead of the practice budget. Services that were provided above the standard service volumes were only remunerated to the doctor on a graduated basis by the Association of Statutory Health Insurance Physicians; Services within the standard service volumes were remunerated with a fixed point value. Each contract doctor was informed of this standard service volume by his health insurance provider one month before the start of the quarter. With this the contract doctor could plan economically. Additional services were only remunerated at the residual point value. This was not determined before the beginning of the quarter, but was only calculated retrospectively, when the quarterly billing of all contract doctors had been carried out, from the service requirements (what all contract doctors have worked out beyond the standard service volume) and the available money. Since the beginning of 2012, the Association of Statutory Health Insurance Physicians (due to the new provisions of the Statutory Health Insurance Supply Structure Act) have again had considerable scope for the distribution of fees , as they did before 2009 . Since then, the distribution via control reserve volumes has only been one possible variant of the fee distribution . As an example, reference is made to the fee distribution scale of KV Bavaria or KV Nordrhein.
Statutory health insurance billing
Four times a year (quarterly), the doctor or psychotherapist notifies his regional association of statutory health insurance physicians (KV) with the names of all those insured by the statutory health insurance companies who have been treated by him in the last 3 months, their diagnoses and the services provided (in the form of the corresponding EBM number) .
The regional KV divides the entire volume of money that is made available to it by all health insurances for these 3 months into different "pots" after certain expenses have been deducted from the total amount in advance. These differ from region to region, for example administrative costs, material costs for dialysis, costs for polyclinic treatments at universities, etc. Then the remaining amount of money is divided into a specialist and a family doctor pot according to a legally defined separation factor. Each specialist group in the specialist physician's pot is allocated a “specialist group pot” that is filled with varying amounts of money. On the basis of the likely size of the specialist group pool, the Association of Statutory Health Insurance Physicians determines the level of the standard benefit volumes for the individual doctors or psychotherapists or applies other distribution criteria. The contract doctor or contract psychotherapist is informed of the fee volume available to him in euros for a quarter 1 month before the start of the quarter. In the case of the control reserve volume, it is calculated from the number of insured persons treated in the comparative quarter of the previous year multiplied by the uniform annual point value and various correction factors, but - since the control reserve volumes are no longer mandatory - it can also result from other algorithms. This means that the contract doctor or contract psychotherapist knows the amount up to which he is guaranteed to treat insured persons (at a fixed point value). If he has reached this limit in the course of the quarter, further services will only be remunerated at the so-called residual point value. This fluctuates very strongly, between 10 and 50% for general practitioners and mostly below 10% for specialists. In their practice management system, contract doctors can see whether the medical or psychotherapeutic work is still being adequately rewarded by the end of the quarter. In particular, specialist groups with high technology costs for each individual examination can no longer cover their costs.
Using the reference times (plausibility times) for numerous EBM numbers, KV also calculates daily and quarterly whether the billing of the services in total is plausible by assuming certain maximum daily working hours for the doctors or psychotherapists. There are also various mutual exclusions and special features. All of this is corrected by the KV as part of the so-called factual and arithmetical correction before the actual accounting run. Administrative costs of the KV (approx. 2.5% of sales, regionally different) and a security deposit are also deducted from the fee.
Individual evidence
- ↑ KV Bayerns, fee distribution scale, valid from July 1, 2012 ( Memento of the original from December 10, 2012 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.
- ↑ KV North Rhine, fee distribution scale from January 1, 2013 ( Memento of the original from January 24, 2013 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; 274 kB)
Web links
- KBV Internet portal for EBM
- Online version of the current complete EBM
- Offline version of the entire EBM (HTML version)
- Daniel Erlemeier Work for Points - How Doctors Are Paid. At n-tv .de on March 26, 2008
- Announcements of the decisions of the evaluation committee according to § 87 paragraph 3 SGB V