Control reserve volume

In Germany, the statutory health insurance associations carry out the billing procedure for outpatient services provided by doctors or psychotherapists for persons with statutory health insurance using the fee distribution standard in accordance with Section 85 (4 ), Book V of the Social Code (SGB V). From January 2009, a legal reform ( GKV Competition Strengthening Act ) brought about a complete reorganization of the remuneration of statutory health insurance physicians. The aim of the standard benefit volumes specified in Section 87b (2) and (3) SGB V and specified by the Extended Evaluation Committee is to limit the medical remuneration for those with statutory health insurance. They have replaced the previously valid practice budgets .

Up to his RLV limit, the doctor or psychotherapist now receives a fixed point value of 3.5001 cents in 2009. Services above this are only remunerated at a fraction. This is intended on the one hand to give the practices planning security and on the other hand to slow down the constant expansion of their medical services.

The KV determines the amount of the RLV from the doctor group-specific case value (i.e. the case value for internists, surgeons, paediatricians, etc.), multiplied by the number of patients (number of cases) that the practice had in the same quarter a year earlier. The physician group-specific case value is determined using a complicated procedure. Essentially, the total remuneration attributable to the RLV is divided among the various groups of doctors in accordance with the earlier fee distribution standards and each portion is then divided by the number of cases in the entire group of doctors.

So there is a "standard fee per patient" for every practice and a maximum number of patients up to which it is paid. For practices with a particularly large number of patients (> 150% of the respective specialist group average), the "excess" patients are only partially counted (25% to 75%). On the other hand, for practices that treat a particularly large number of pensioners who generally need more treatment, correction factors should be used upwards. There are further correction factors, surcharges and deductions of lesser importance. The RLV change every three months and should be communicated to the practice owners in good time before the start of the quarter.

The z. B. RLV announced by KV Nordrhein are currently between 11 € and 110 € per patient and quarter. If more services are provided than are contained in the RLV, they will only be remunerated at the so-called graduation point value, which is in the order of 0.3 cents per point.

Some of the possible services, e.g. B. skin cancer screening , acupuncture , or radiation therapy for cancer patients, is not subject to the RLV, but is limited as before by the fixed upper limit of the total remuneration (i.e. the total amount that the statutory health insurance pays the statutory health insurance association in a certain year): if these services are increasingly provided, the point value and thus the remuneration per individual service decrease. A few services that are particularly politically promoted (e.g. mammography screening) are not limited by the RLV or the agreed total remuneration, but are remunerated to the doctors with a fixed point value without any quantity restrictions .

In order to mitigate economic upheavals, the statutory health insurance associations have created transitional regulations.

Control reserve volume

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