Private liquidation

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With a private liquidation, doctors and dentists claim remuneration from a treatment contract for their professional services, i. In other words, they will invoice the patient for the private medical treatment carried out according to the rules of medical art for medically necessary medical care or at the request of the payer . The term liquidation used for this is derived from the Latin liquidus = liquid and in this context means to issue an invoice for a service provided, that is to "liquefy" the medical efforts.

Private medical liquidation is regulated in Germany in the fee schedule for doctors (GOÄ), the fee schedule for dentists (GOZ) and the fee schedule for psychological psychotherapists and child and adolescent psychotherapists (GOP).

applicability

Private accounting is only permitted unless otherwise stipulated by federal law.

The remuneration of the doctors and facilities participating in contract medical care is regulated by the state associations of the health insurance funds and the substitute funds with the statutory health insurance associations through general contracts ( Section 82 (2) sentence 1 SGB ​​V ). In accordance with the general contracts, the health insurance company pays total remuneration to the respective statutory health insurance association with discharging effect for the entire statutory medical care of its members residing in the district of the statutory health insurance association, including the family members that are also insured ( Section 85 (1) SGB V). The insured receive the benefits of their health insurance as material and services ( § 2 Abs. 2 Satz 1 SGB V) in the form of a medical treatment. The insured persons pay their contributions to the health insurance companies, which, in the event of treatment, settle the services provided to the legally insured persons via the statutory health insurance associations with the service provider (e.g. the treating doctor). The attending physician will not be billed to the insured person for services that are the subject of statutory medical care, i.e. sufficient, appropriate and economical ( Section 12 SGB ​​V). However, instead of the benefit in kind principle , those with statutory health insurance can also choose to be reimbursed ( Section 13 SGB ​​V) and take advantage of individual health services . A private liquidation is also permitted if the insured person does not present the electronic health card (Section 18 (8) Federal Shell Contract BMV).

Conversely, those privately insured in the basic tariff can agree with the attending physician that the doctor will not settle with them but directly with their private health insurance.

Calculable services

The fee schedule differentiates between fees, compensation and reimbursement of expenses ( § 3 GOÄ). The regulations in GOÄ and GOZ are essentially the same. Deviations are expressly mentioned in the text.

fees

Fees ( § 4 GOÄ) are remuneration for the medical services specified in the schedule of fees (Appendix 1 to GOÄ / GOZ). The doctor can only charge fees for independent medical services that he has provided himself or that have been provided under his supervision according to professional instructions (own services). The on-call duty and the availability of a doctor or medical team are not billable. The fees cover the costs of the practice, including the costs for consultation hours and the costs for the use of instruments and apparatus, and may not be charged separately.

compensation

As compensation ( §§ 7 to 9 GOÄ) for visits, the doctor receives a travel allowance based on the distance traveled to the patient, and a travel allowance for visits over a distance of more than 25 kilometers. This compensates for missed time and the additional costs caused by the visit (e.g. fuel costs).

Reimbursement of expenses

In the case of doctors, these are in particular the costs for those drugs, bandages and other materials that the patient keeps for further use, as well as actual shipping and postage costs. The calculation of flat rates is not permitted. Small materials such as cellulose or gauze swabs, low-quality drugs for immediate use or disposable items such as disposable syringes or gloves are not billable. Rather, these are covered by the fees ( § 10 GOÄ).

In addition to the fees provided for the individual dental services, the reasonable costs actually incurred by the dentist for dental technology services can be charged as expenses, provided that these costs are not covered by the fees in accordance with the provisions of the fee schedule ( § 9 GOZ).

Amount of remuneration

The amount of the individual fees is based on one to three and a half times the fee rate. Within the fee framework, the fees are to be determined at reasonable discretion ( § 315 BGB ) , taking into account the difficulty and the time required for the individual service as well as the circumstances during the execution . Fees for medical-technical services are calculated from one to two and a half times the fee rate, in average cases 1.8 times the fee rate. Fees for laboratory services are calculated from one to 1.3 times the fee rate, in average cases from 1.15 times the fee rate ( § 5 GOÄ).

It does not constitute a misuse of discretion if the doctor bills personal-medical and medical-technical services of average difficulty at the respective maximum rate of the standard range, i.e. 2.3 times or 1.8 times the fee rate.

This case law has meanwhile found its way into the fee schedule. 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 permissible if special features justify this and must be justified in the invoice for the payer in an understandable and comprehensible manner. The 2.3 times the fee rate represents the average performance in terms of difficulty and time required. Services with a below-average level of difficulty or expenditure of time are to be charged at a lower fee rate ( Section 5 (2) sentence 4 GOZ in the version applicable since January 1, 2012).

In the event of a lawful termination of a pregnancy , fees may only be charged up to 1.8 times the fee rate ( § 5a GOÄ).

For services that are insured in a standard private health insurance tariff, fees for medical services may only be up to a maximum of 1.7 times, fees for medical-technical services only up to a maximum of 1.3 times and laboratory services only up to a maximum of 1.1 times Fee rate ( § 5b GOÄ). These increase rates correspond to the reduced scope of insurance in the standard tariff compared to normal tariffs.

Conversely, results from the fact that for the base rate , the generally accepted rates may Insured are settled, although the tariff reimbursement services of private health insurance is even lower in the basic rate than the standard tariff (medical services 1.2 times, medical-technical services 1,0facher and laboratory services 0.9 times the fee rate).

Deviating agreement

By agreement ( § 2 GOÄ), a different fee level can only be set for personal medical services. Emergency and acute pain treatment must not, however, be made dependent on an agreement. The agreement must be made in writing after personal consultation between the doctor and the debtor in individual cases before the doctor provides the services. In addition to the number and description of the service, the rate of increase and the agreed amount, the agreement must also state that reimbursement of the remuneration by reimbursement agencies may not be fully guaranteed. The agreement may not contain any further explanations. The doctor has to give the debtor a copy of the agreement.

The reimbursement of private health insurance companies is usually limited to 3.5 times the rate of increase. Doctors may agree to higher rates of increase, but the patient must bear the difference to the reimbursement amount for his insurance.

Individual health services (so-called IGeL) may only be billed to those with statutory health insurance if a written treatment contract has been concluded with the insured person before the start of treatment.

Due date

The remuneration is due when the debtor has been issued with an invoice that meets the requirements of the GOÄ ( § 12 GOÄ).

In particular, the invoice for outpatient services must contain:

  1. the date of performance of the service,
  2. in the case of fees, the number and description of the individually charged service including a minimum duration, if applicable, as well as the respective amount and the rate of increase,
  3. in the case of compensation, the amount, the type of compensation and the calculation,
  4. in the case of reimbursement of expenses, the amount and type of expenses,
  5. in the case of dentists, the type, quantity and price of materials used ( § 10 GOZ).

Dentists must use an official liquidation form (Appendix 2 to the GOZ) for their billing.

Medical treatments in the field of human medicine that are provided in the course of working as a doctor or dentist are not subject to sales tax ( Section 4 No. 14a UStG). When issuing the invoice, the information in accordance with 14 UStG, in particular the indication of a tax number or sales tax identification number .

Billing

Doctors and dentists may, with the patient's consent, have the billing carried out by third parties in order to reduce the administrative work in the practice. Private medical clearing houses offer their services for this. The doctor forwards the billing-relevant data to the clearing house.

Furthermore, there is the possibility that the doctor again, with the patient's consent, sells the fee claim against the patient to a clearing house (real factoring ). The doctor receives 80 to 90% of his claim from the clearing house. This takes over the further claims management and is entitled to assert the services provided by the doctor in their own name with the patient out of court and in court and to enforce them after judicial determination. In these cases, the doctor no longer bears the risk of default. If the patient refuses to pay and civil proceedings are necessary to enforce them , the clearing house is the party to the proceedings as the plaintiff. This allows the doctor to be questioned as a witness to provide evidence.

Disputes between doctor and patient or private health insurance about the quality of the service provided or the amount of the calculated remuneration can be resolved through fee reports, among other things .

Individual evidence

  1. ↑ liquidate Duden.de, accessed on September 5, 2019
  2. ↑ Information on private liquidation for GKV-insured persons with the IGeL list of the Bavarian Association of Statutory Health Insurance Physicians , as of August 2017
  3. ↑ § 6 Paragraph 3 of the General Insurance Conditions 2009 for the basic tariff (MB / BT 2009) §§ 1 - 18, BT tariff (as of January 1, 2012).
  4. ↑ Federal Court of Justice judgment of November 8, 2007 - III ZR 54/07 .
  5. ^ Federal Constitutional Court decision of October 25, 2004 - 1 BvR 1437/02 .
  6. ↑ Section 3, Paragraph 1, Clause 3 of the Federal Sheath Contract - Doctors of August 31, 2019. PDF
  7. ^ Axel Otte: Sales tax: case law in the sense of the Doctors Deutsches Ärzteblatt 2012; 109 (33-34): A-1715 / C-1369
  8. ↑ Federal Ministry of Finance : VAT exemption according to § 4 No. 14 letter a UStG; Value added tax treatment of the services of alternative practitioners and health professions circular of June 19, 2012
  9. ↑ Marlis Hübner: Mandatory information on a doctor's bill. Deutsches Ärzteblatt 2010; 107 (28-29): A-1424 / B-1260 / C-1240.