Reimbursement of costs (health insurance)

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In German health insurance , reimbursement of costs means that insured persons first settle the medical services provided directly with the service providers (doctors, psychotherapists) and then get these costs reimbursed by the health insurance company.

The cost reimbursement principle is the rule in private medical treatment and in private health insurance (PKV), in statutory health insurance (GKV) the exception to the prevailing principle of benefits in kind , which determines that the contract doctors pay the services provided to the insured directly to the health insurance companies - as a rule - settle accounts via the statutory health insurance associations.

In the GKV there is reimbursement of costs as an optional service according to Section 13 (2) SGB V and as a fallback service in the event of system failure according to Section 13 (3) SGB V.

Reimbursement of costs as an optional service

In accordance with the benefits in kind principle , the patient identifies himself as a member of a health insurance fund with his electronic health card and receives the benefits that are considered to be economical, sufficient, necessary and expedient according to Section 12, Book V of the Social Code (SGB V); so not necessarily the maximum of the medically possible services. Since January 1, 2004, those insured with statutory health insurance have the option of opting for reimbursement instead. Since April 1, 2007, this decision can be restricted to the area of ​​medical care, dental care, inpatient care or to services provided according to Section 13, Paragraph 2, Fifth Book of the Social Code (SGB V). Until the end of 2010, the commitment period was one year. Since January 1, 2011, patients have been bound by their decision for three months.

In practice, this option has so far only been chosen by a few insured persons (as of 2018), which is attributed to the difficulties and risks of this type of benefit for the insured.

The insured person can choose the reimbursement of costs after they have been informed about this by the service provider. Information is also available on the websites of the statutory health insurance associations. Advice or approval from the health insurance company is no longer required.

After this decision, the patient becomes a self-payer ( private patient ) and receives invoices according to the official fee schedule for doctors (GOÄ), fee schedule for psychological psychotherapists and child and adolescent psychotherapists (GOP) or the fee schedule for dentists (GOZ), which he sends directly has to pay the doctor , dentist , psychotherapist or health care provider . The reimbursable portion is reimbursed through his fund. This is the amount that would have been paid if the health insurance fund fee regulations had been applied (doctors: EBM Uniform Assessment Standard , Dentists: BEMA Assessment Standard for Dental Services ), minus a flat rate of up to 5%, which varies depending on the health insurance company, for administrative expenses and the lack of a profitability audit.

Most health insurances also accept assignments from patients, so that doctors can settle accounts directly with the health insurer and the patient is spared administrative work.

The fee regulations GOÄ / GOP / GOZ of the PKV and EBM / BEMA of the GKV are partially incompatible. The fee schedules often provide for much higher remuneration than the uniform assessment standard. Some services can be calculated by a private doctor, but have no equivalent in the EBM / BEMA of the GKV. It can happen that large parts of the private bill are not reimbursed by the health insurance companies. Only in the case of psychotherapy is there little or no additional payment in the cost reimbursement procedure, as the current rates for psychotherapy within the framework of the statutory health insurance (including the quarterly flat rates) hardly differ from those of the private fee schedule.

To ensure that applications for reimbursement are not delayed, the Federal Ministry of Health made it clear in 2013 that applications are considered approved if they are not decided within a maximum of five weeks.

Because high deductibles can arise, especially in the event of a serious or protracted illness, the choice of reimbursement can currently only be recommended without restriction to GKV insured persons who either have private outpatient residual cost insurance or are eligible for subsidies . Insured persons without such additional insurance should inquire with their health insurance company whether the excess is limited per year. Several health insurance companies offer such an "airbag". The 2007 health reform provides for a strengthening of the cost reimbursement principle for GKV insured persons by allowing the GKV to offer optional tariffs that also reimburse the remaining costs.

Reimbursement of costs in the event of system failure

Section 13 (3) SGB V states: "If the health insurance company could not provide a service that cannot be postponed in time or if it has wrongly refused a service and the insured person incurred costs for the self-procured service, the health insurance company is entitled to the amount incurred reimbursement if the service was necessary. The costs for self-procured services for medical rehabilitation according to the ninth book are reimbursed according to § 15 of the ninth book. "

In the opinion of the Ärzteblatt, this regulation is particularly important for the mentally ill because it means that "[...] mentally ill people who have looked in vain for a therapy place with a psychotherapist approved in the health insurance system, also approved psychotherapists who work in private practice without approval, to seek out. "

In the past ten years, expenses for reimbursement of costs for psychotherapy according to Section 13 (3) SGB V have increased almost eightfold. However, they are still low in absolute terms: in 2012 they amounted to 45 million euros with a total service volume of around 1.5 billion euros for outpatient psychotherapeutic services.

controversy

The reimbursement of costs was controversial when it was introduced.

The legislature expected the introduction of a better cost consciousness and more economical behavior of the patients; The doctors and psychotherapists hoped for their group to reduce bureaucracy and make accounting easier. (With the principle of benefits in kind, restrictions and benchmarks apply to prescriptions of drugs and therapeutic products , some of which are reinforced with claims for recourse .)

Critics feared that patients would be deterred from meaningful doctor and psychotherapist visits, or that meaningful services and prescriptions would be withheld from them. The National Association of Statutory Health Insurance Funds expected an increased administrative burden for its member funds. Self-payers could e.g. B. be preferred for psychotherapy.

The health insurance only pays its share if a doctor or psychotherapist with health insurance is consulted ; with purely private doctors or private psychotherapists, corresponding supplementary health insurance only partially or not at all, depending on the tariff. Even if doctors with statutory health insurance are used, not every tariff pays for 100% of the remaining costs. Furthermore, the reimbursement process is complicated by the fact that the insured person has to submit his reimbursement claim to two billing offices, the health insurance company and the private supplementary health insurance company. This process is thus similar to the reimbursement procedure for persons entitled to aid .

Individual evidence

  1. State of affairs : Choice of reimbursement by insured persons in the statutory health insurance according to § 13 paragraph 2 SGB V. In: WD 9 -3000 -073/18. Scientific Services, German Bundestag, 2018, accessed on July 12, 2019 . P. 7.
  2. Jana Hauschild: Zoff about reimbursement: Health insurers harass psychotherapy patients. Spiegel online, April 13, 2013
  3. Heinfried Tintner: § 13 Reimbursement of costs / 2.3.2 Impossibility of timely granting of benefits (Paragraph 3 Clause 1 1st alternative ) Rz. 33-35. haufe.de, accessed on February 17, 2019
  4. Tim C. Werner: The claim for reimbursement of § 13, paragraph 3, sentence 1, 2nd alternative SGB V without year, accessed on February 17, 2019
  5. Petra Bühring: Interview with Felix Jansen, psychological psychotherapist: “Reimbursement definitely offers more freedom” Deutsches Ärzteblatt, September 2013
  6. Newsletter of the Federal Chamber of Psychotherapists, Issue 4, December 2013 ( PDF ( Memento of the original from September 23, 2015 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice . ) @1@ 2Template: Webachiv / IABot / www.bptk.de
  7. German Bundestag printed matter 18/2140: Response of the Federal Government to a small question, July 17, 2014 ( PDF )
  8. Severin Weiland: Pay for every visit to the doctor: Rösler's "prepayment" principle causes outrage. Spiegel online, Sept. 30, 2010
  9. Martin Wortmann: Controversy about reimbursement - who is it good for? Who is at what risk? Doctors newspaper May 25, 2010
  10. Reimbursement. ( Memento of the original from June 2, 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. Patient brochure of the Federal Chamber of Psychotherapists, 2012 (PDF) @1@ 2Template: Webachiv / IABot / www.bptk.de