Private patient
Private patient is the colloquial term in Germany for a patient who - detached from the provisions of SGB V , which define the treatment framework for statutory health insurance - concludes a private treatment contract with a doctor , psychotherapist , dentist , hospital , pharmacy or other health professional . Fees and charges are billed directly to the private patient. This self-pay is the so-called " panel patient over" in which the National Health Insurance (SHI) after the payment in kind principle indirectly via the physicians 'Association (KV) or the dentists' association the physician psychotherapist or dentist performance by varying point value paid or a lump paid.
Private patients can insure themselves with a private health insurance (PKV) or take out additional insurance . A form of basic security for civil servants is the allowance , which usually reimburses half of the invoice amount. Private health insurance covers the remainder within the framework of its tariff regulations.
Legal requirements
Since January 1, 2009, there has been a general health insurance obligation , according to which health insurance is no longer voluntary, but is made mandatory by law .
Opportunities for legally insured persons
With the change in §13 SGB V, however, a possibility was created to enable members of health insurance companies to receive private medical or private psychotherapeutic treatment with partial or full coverage of costs. For this purpose, the health insurance patient switches to the cost reimbursement principle and also takes out an outpatient residual cost insurance , which then reimburses the costs incurred at private insurance level together with the statutory health insurance. The method of billing and reimbursement of the bill is analogous to that of private patients.
Longer waiting times for those with statutory health insurance
A study by the RWI - Leibniz Institute for Economic Research and Cornell University confirmed the suspicion that people with statutory health insurance have to wait significantly longer for a specialist appointment. As part of a field experiment , a test person asked for appointments at almost 1000 specialist practices across Germany: the practices offered the privately insured an appointment with a statistically significantly higher probability. When an appointment was offered, the publicly insured had to wait on average more than twice as long as private patients.
Reward
The fee is based on the fee schedule for doctors (GOÄ), the fee schedule for psychotherapists (GOP) and the fee schedule for dentists (GOZ). The fee is calculated by multiplying a rating number with the valid point value and an increase factor that ranges between the simple and three and a half times the rate. The latter is determined according to "difficulty, time required and special circumstances" (Section 5 (1) GOZ). If the 2.3-fold rate is exceeded, a reason must be given. The justification can be given in ongoing legal proceedings to review the assessment factor up to the end of the last oral hearing. A previous fee agreement is required to exceed 3.5 times the rate. After the private patient has submitted the invoice to his insurance company, he will be reimbursed for the cost shares agreed in the collective agreement. Similarly, the private patient pays the prescribed medication in the pharmacy and then submits the prescription for reimbursement.
reimbursement
Private health insurances work according to the reimbursement principle. The patient first pays himself and in the next step has the reimbursable costs covered by the health insurance.
Outpatient treatment
As a rule, doctors and psychotherapists grant the patient a payment period of up to four weeks. Most insurance companies transfer the insurance benefit to the insured within 14 days. As a result, he does not need to pay in advance. Medicines and aids (e.g. glasses or hearing aids) must first be paid for out of pocket. The invoice is then submitted to the insurance company.
Inpatient treatments
Hospital administrations send invoices for inpatient accommodation directly to the health insurance, which transfers the invoice amount directly to the hospital in question. In order to identify themselves as a private patient, the privately insured person needs his chip card (clinic card). The patient does not have to worry about the payment process. He receives a copy of the invoice for information. Unlike bills for accommodation costs, bills from hospital doctors - like medical bills for outpatient treatment - are sent to the patient.
In the case of optional services (see hospital treatment # optional services ), the patient receives individual bills from each chief doctor / elective doctor who was involved in the hospital treatment when using optional medical services. The calculation of the medical, psychotherapeutic and medical optional services is based on the fee schedule for doctors (GOÄ). In the case of bills from external doctors of choice (doctors commissioned by doctors of choice in the hospital where the patient is located), they must be reduced by 15 percent.
Aid
The beneficiary submits the original receipt (invoice, prescription, etc.) to the private health insurance company and a copy of the receipts to the aid office. Insurance and aid agency reimburse the respective share to the submitter.
Assignment
According to Section 6 (6) of the model conditions for health insurance, it is excluded that the policyholder (private patient) assigns the claims to insurance benefits . This is to prevent the insured against being called upon by one or more other creditors instead of his policyholder, i.e. in the event of damage he has to process the contractual relationship with third parties and in the event of a lawsuit he has to accept the witness of the policyholder.
However, in good faith ( § 242 BGB), private health insurance may be prevented from invoking the agreed ban on assignment if it is no longer covered by an interest within the scope of the clause, for example if a travel insurer who is only liable to pay subsidiary benefits due to a Obligation to make advance payments for illness and repatriation costs has been submitted or if the privately insured patient would find it difficult to enforce a claim for damages against the doctor or hospital operator because he or she cannot cede the claim for reimbursement to them.
If the privately insured person's claim for reimbursement is to be assigned to the doctor, psychotherapist or dentist in order to enable direct billing between the doctor and the insurance company, the insurance company must agree to the assignment due to the contractual prohibition of assignment.
Statutory subrogation
According to Section 86, Paragraph 1 of the Insurance Contract Act (VVG), the following applies: If a policyholder has a claim for compensation for damage against a third party (in this case the doctor, psychotherapist or dentist), this claim for compensation is transferred to the insurance company if the policyholder pays the damage has replaced. This means that claims due to alleged malformed treatment can be transferred to the insurer, as these are claims for damages . This - to a certain extent automatic - assignment can be excluded in accordance with § 399 BGB by means of a written agreement prior to the start of treatment.
It is legally controversial whether this “automatic” transfer of claims to the insurance also applies to so-called enrichment claims , which result from the fact that the practitioner allegedly billed non-billable expenses or services.
Number of private patients
The number of people insured in private health insurance in Germany as of June 30, 2012:
| Privately insured | number |
|---|---|
| Fully insured | 8.95 million |
| Supplementary insured | 21.09 million |
| of which: those with additional dental insurance |
12.2 million |
Distribution of the privately fully insured:
| Privately insured | proportion of |
|---|---|
| Civil servants and retirees | 42% |
| Not employed (including children) | 19.9% |
| Self-employed | 15.7% |
| Employees | 11.6% |
| pensioner | 7.5% |
| students | 2.9% |
| Unemployed | 0.2% |
78 percent of those with full private health insurance have an income below the annual wage limit of 50,850 euros per year. (Children were not included because they had no income.)
Advantages as a private patient
Advantages of the private patient are to be distinguished from those of the privately insured .
Private patient
- The self-payer often expects a preferred schedule.
- For the doctor or psychotherapist, there is no need for a profitability audit by the joint review committees of the health insurance companies and associations of statutory health insurance physicians or statutory health insurance physicians, and they can prescribe the drugs and applications and use the therapies that they consider appropriate without restricting collective budgets.
- Private patients can also claim services and medication that go beyond the scope of the statutory health insurance service catalog. (Depending on the tariff selected, services from a more extensive catalog of services (tariff-specific) may be reimbursed later)
- Depending on the tariff, treatment by the chief physician can be claimed in the hospital.
- Depending on the tariff and, of course, availability, hospital accommodation in a single or twin room can be claimed.
Privately insured
- Thanks to the reimbursement principle, the costs of the treatments are transparent for the insured person (those with statutory health insurance can, however, ask for a patient receipt).
- Depending on the selected tariff, the following are possible:
- Cheaper insurance premiums for single people compared to health insurers (depending on taxable income).
- More extensive benefits than in the context of statutory compulsory insurance.
Disadvantages as a private patient
Disadvantages of the private patient are to be distinguished from those of the privately insured .
Private patient
- The temporary pre-financing of the due invoice settlement together with the costs exceeding the contractual reimbursement (doctor's fee, psychotherapist's fee, physiotherapy treatment, medication, etc.) is a financial burden that should not be underestimated in addition to the current insurance premium. (In order to counteract the burden of pre-financing, almost all private health insurance companies offer a health insurance card as proof of coverage analogous to the health insurance card in the statutory health insurance.) - cf. Insurance tariff regulations.
- For relatives who are privately insured through another person (spouse and children) it may be undesirable in individual cases for the main insured person to receive knowledge of all medical treatments when the bills are sent to him.
Privately insured
- There is a risk of overtreatment, of unnecessarily prescribed examinations and treatments.
- Settling the bill and applying for reimbursement create a greater bureaucratic effort for the privately insured . If this represents excessive demand for a person, for example a person in need of care, high costs may arise ( dunning fees and late payment surcharges or refused reimbursements due to missed application deadlines). It may be necessary to transfer the task to a relative or a supervisor who needs an account authorization for this.
- The privately insured person is obliged to check whether the services listed in the medical bills have actually been carried out and whether the bills are plausible . He must point out any inconsistencies to the insurance company; if he has negligently failed to notice that treatments not provided have been billed, he may have to be liable for this years later .
- Statutory health insurance patients are sometimes offered additional so-called " Individual Health Services (IGeL)", the necessity or even benefit of which, however, is often controversial.
- Exclusions from previous illnesses are common.
- There are reimbursement limits and individually contractually agreed deductibles.
See also
- Private doctor
- Private psychotherapist
- Private dentist
- reimbursement
- Differences between statutory and private health insurance
- Two-class medicine
Web links
Individual evidence
- ↑ Social Code V. Accessed on May 11, 2016 .
- ↑ RWI study: Specialists prefer private patients. idw - Science Information Service. June 25, 2020 (accessed July 2, 2020)
- ↑ How to find the right rate of increase in the GOÄ
- ↑ Model conditions of the PKV
- ↑ Consumer advice center NRW: "Fee schedule for doctors" ( page no longer available , search in web archives ) Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice.
- ↑ Consumer advice center NRW: "How much do optional services cost?" ( Memento of the original from April 25, 2015 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.
- ↑ Wording of Section 6, Paragraph 6 of the model terms and conditions: "Claims to insurance benefits can neither be assigned nor pledged."
- ↑ a b Judgment of the Federal Court of Justice (BGH) of April 21, 2004 - IV ZR 113/03
- ↑ Regional court Karlsruhe judgment of July 15, 2005, 5 S 124/04
- ↑ Number of people insured in private health insurance in Germany (as of June 30, 2012)
- ↑ PKV Publik 07/2012, Scientific Institute of PKV (WIP): Structure of the PKV insured
- ↑ PKV boss after massive premium increases: The interest is to blame focus.de, on December 15, 2016
- ↑ Munich District Court, ref .: 282 C 28161/12. Quoted from: Press release 7/14. Munich District Court, February 24, 2014, accessed on February 15, 2015 .
- ↑ sueddeutsche.de , accessed on October 30, 2012.
