Benefits in kind principle
The principle of benefits in kind is one of the structural principles of statutory health insurance in Germany and is legally stipulated in Section 2 of Book V of the Social Security Code (SGB V). It includes the provision of medical material and services by the health insurance company. The patient , d. H. Either the health insurance member or a co-insured family member then uses the health insurance services for the health insurance itself without receiving an invoice from the service provider . The opposite is the reimbursement principle . The health insurance company reimburses its members for the costs of the medical treatment provided by the service providers. The principle of benefits in kind also applies to social long-term care insurance and statutory accident insurance .
execution
The health insurance companies provide the services through contract doctors and dentists , contract psychotherapists and other service providers. These account for their services through the responsible statutory health insurance or statutory health insurance association or directly with the insured's health insurance company. The service providers are limited to reimbursement claims against the health insurance company; the insured person is not obliged to reimburse.
The catalog of services is bindingly determined by federal contracts between the central association of health insurers on the one hand and the National Association of Statutory Health Insurance Physicians or National Association of Statutory Health Insurance Dentists on the other hand, and also by the Federal Joint Committee (G-BA). The insured persons who make use of the goods or services present their electronic health card or health insurance card , a referral slip or a prescription to the service providers , whereby they can prove that they are entitled to benefits .
discussion
advantages
By billing the services via the Association of Statutory Health Insurance Physicians, the flow of money to doctors and dentists - within the framework of the billing and fee distribution standards - is secured. There is no risk of default by defaulting patients. The administrative effort is reduced because the practitioner does not have to spend any additional time invoicing, monitoring incoming payments, dunning etc. for each individual patient.
For the patients themselves, the billing and reimbursement processing is largely unnecessary, as they do not have to submit any bills for reimbursement and do not have to make any financial advance payments. For low-income patients, upfront payment can be a financial burden. You are also protected from excessive financial demands.
disadvantage
The disadvantage of the benefit-in-kind principle is that the patient does not find out what costs he incurs for medical treatment, medication, physiotherapy, hospital treatment, etc. for the community of insured persons. The consequences are carelessness when it comes to claiming behavior, expectations and the susceptibility of the system to manipulation. This results in considerable bureaucratic control, monitoring, regulation and rationing mechanisms.
Due to the prohibition of additional payments and the economic efficiency requirement of the statutory health insurance, the patient is only entitled to a limited scope of benefits. The prohibition based on the statutory health insurance system and resulting from the SGB V to demand (additional) payments from the insured person ( Section 95 Paragraph 3 in conjunction with Section 2 Paragraph 2, Section 13 Paragraph 1 SGB V), which as Additional payment prohibition in Section 18 (3) Federal Medical Insurance Contract - Doctors (BMV-Ä) and § 21 (3) Substitute Health Insurance Contract - Doctors (EKV-Ä), as standardized in the Federal Medical Insurance Contracts / Substitute Insurance Contracts for Dentists, applies in principle to all contract medical services.
literature
- Fischer, Mattias G .: The principle of benefits in kind - an inviolable original principle of statutory health insurance? , in: Die Sozialgerichtsbarkeit (SGb) 2008, pp. 461–466
Individual evidence
- ↑ Federal cover contracts (homepage of the National Association of Statutory Health Insurance Physicians) ( Memento of the original from January 28, 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.
- ↑ Federal shell contracts (homepage of the National Association of Statutory Health Insurance Dentists)
