Backup order

from Wikipedia, the free encyclopedia

The security order is a legal institution from the law of the statutory health insurance and concerns the legal relationships of the health insurance companies to doctors, dentists, psychotherapists, pharmacies, hospitals and other service providers . The provision of contract medical and contract dental care is regulated in the fourth chapter of SGB ​​V (§§ 69 ff. SGB V). Its goals are needs-based care for the insured, appropriate remuneration for medical services and stable contribution rates .

term

According to Section 75 SGB ​​V, the statutory (dental) medical associations and the National Associations of Statutory Health Insurance Physicians have to ensure contractual medical and contractual psychotherapeutic care to the extent specified in Section 73 (2) SGB V and to guarantee the health insurance companies and their associations that the Contract medical and contract psychotherapeutic care complies with legal and contractual requirements. The guarantee also includes the appropriate and timely provision of specialist medical care and contractual medical care during non-office hours ( emergency service ).

The term "security" is not defined by law. Generally, however, a distinction is made between general and special backup orders.

General backup order

The general security mandate for statutory health care is regulated in Section 72 (1) SGB V. According to this, service providers and health insurance companies work together to ensure that the insured are covered by a medical contractor. According to the case law of the Federal Social Court, the location in the first title of the second section of SGB V on the relationships between the health insurance companies and the service providers makes it systematically clear what importance is attached to ensuring statutory medical care, which is factual and financial Regard is a "common good of considerable weight".

The most important instrument and formative for the contract doctor system are collective-legal written contracts between the associations of statutory health insurance physicians and the associations of the health insurance companies according to certain content-related specifications (Section 72 (2) SGB V). The content of the contracts is adequate, expedient and economical care for the insured (§§ 12, 70 SGB V) as well as adequate remuneration for medical services in order to offer the doctors a sufficient incentive to be licensed by a contract doctor . A significant example is the federal shell contract ( Section 82 (1) SGB V).

Special security orders

Members of the GKV

The special order according to Section 75 (1) of the Social Code Book V to ensure statutory medical care to the extent specified in Section 73 (2) of the Social Code Book V is fulfilled by the statutory health insurance associations by approving a sufficient number of service providers who are then entitled to participate in statutory medical care by way of benefits in kind are obligated ( § 95 Abs. 1, Abs. 3, § 96 SGB ​​V).

According to Section 20 (1) of the Admission Ordinance for Contract Doctors (Doctors ZV), the doctor or psychotherapist must be personally available to the insured person, in particular offering consultation hours at the times usual for contract doctor care. In this respect, he is included in the security order incumbent on the KV to carry out proper care. The security order also includes the provision of statutory medical care when there are no consultation hours ( emergency service ) as well as the timely arrangement of treatment appointments by appointment service centers ( Section 75 Paragraph 1a, 1b SGB V).

In accordance with the principle of benefits in kind, the contract doctor specifies the claims of the insured against the health insurance companies, defines the patient's illness and the need for medical and other services and benefits in kind. Insured persons cannot claim benefits that are not necessary or uneconomical, the service providers may not provide them and the health insurance companies may not approve them ( Section 12 (1) sentence 2 SGB V). The claim for remuneration is not directed against the insured person, but with the responsible association of statutory health insurance physicians ( Section 630a (1) BGB, Section 85 (1), 87b SGB V).

The insured, in turn, can claim benefits in kind from the statutory health insurance provider at any time without having to reach an agreement with the treating contract doctor in individual cases on the type and scope of the benefits and their remuneration. This is because the contract physicians only provide the services in kind and services that cannot be directly provided by the health insurers themselves, without these services being at the disposal of the service providers (§§ 2, 12 SGB V).

The KVs enforce the proper fulfillment of the statutory health insurance obligations by virtue of the disciplinary power assigned to them in Section 81 (5) SGB V, which they must use to ensure care, Section 75 (2) SGB V.

Extensions

Section 75 (3–6) of the Social Code Book V expand the statutory security mandate beyond the provision of statutory health insurance.

Beneficiaries

Section 75 (3) SGB V concerns the medical care of people who, based on the statutory provisions on the granting of medical care, are entitled to free medical care and are exempt from insurance in the GKV ( Section 6 (1) No. 2 SGB V), for example, law enforcement officers of the federal police. This is acc. Section 70 (2) BBesG granted curative care. The medical care is generally granted as a benefit in kind, the medical care benefits correspond to the benefits of the statutory health insurance according to the fifth book of the Social Security Code (§§ 2, 4 Federal Police Heilfürsorgeverordnung).

Prisoners

As a rule, the insurance relationship ends for compulsorily insured persons of the statutory health insurance because of the imprisonment, as the facts giving rise to the compulsory insurance such as employment for wages, the receipt of unemployment benefit or unemployment benefit II according to Section 5 (1) No. 1 to 2a SGB V does not apply. In the case of voluntary health insurance, a health insurance obligation due to a pension application or due to the drawing of a pension from the statutory pension insurance, the insurance relationship remains in effect even during imprisonment, but the benefits are suspended for the duration of the detention ( Section 16 (1) No. 4 SGB V). The prisoners have a priority right to health care according to the penal law (cf. § 61 StVollzG), which is based on the equivalence principle of § 3 Abs. 1 StVollzG on the general living conditions and thus on the requirements of the statutory health insurance companies.

Section 75 (4) SGB V includes the medical treatment of prisoners in penal institutions in emergencies outside the working hours of the prison doctors and dentists in the security order.

Miners health insurance

Insofar as the medical or psychotherapeutic care in the miners 'health insurance of the Deutsche Rentenversicherung Knappschaft-Bahn-See is not ensured by miners' doctors, the associations of statutory health insurance physicians outside the traditional mining regions must ensure the care of the miners insured (Section 75 (4) SGB V).

Insured in the standard and basic tariff

The National Associations of Statutory Health Insurance Physicians and the National Associations of Statutory Health Insurance Physicians have according to Section 75 (3a) sentence 1 SGB V also ensure the medical care of those privately insured in the industry-standard standard and basic tariff as well as the emergency tariff with the medical services insured in these tariffs.

To the security according to According to Section 75, Paragraph 3a, Sentence 1 of the Book V of the Social Code, the requirements to be met are no lower than those of ensuring the statutory health insurance of those insured according to Section 75 (1) and (2) SGB V. In contrast to the other persons listed in Section 75 SGB V, these insured persons have no claims for benefits in kind against the contracted doctors and dentists. Insofar as a statutory health insurance association does not oblige its members to treat insured persons of the basic tariff, the contract doctors are free to choose whether to treat this group of insured persons. So you have the choice of either receiving treatment on the terms of the basic tariff or refusing such treatment.

Transfer of the security order

§ 72a SGB ​​V provides for the transfer of the security order to the health insurance companies if more than half of all contract doctors established in a licensing district or a regional planning area renounce their license according to § 95b paragraph 1 or the contract doctor or contract psychotherapeutic care has been refused and determined that the supply is no longer guaranteed. In this case, the health insurance companies or the regional associations of the health insurance companies and the substitute funds conclude jointly and uniformly individual or group contracts directly with doctors, psychotherapists, dentists, hospitals or other suitable institutions. You can also use your own facilities according to Establish Section 140 (2) SGB V.

According to a survey carried out from the end of November 2012 to the beginning of January 2013 on behalf of the National Association of Statutory Health Insurance Physicians (KBV), the vast majority of all around 150,000 contract doctors and contract psychotherapists in Germany would like the medical self-administration to continue to take care of the security mandate for outpatient medical care. However, most of them only support this if the framework conditions change significantly, for example in the case of the freedom of medical therapy and drug regulation restricted by the guidelines of the Federal Joint Committee (GBA) , recourse and increasing administrative effort in everyday practice, for example by issuing written prevention recommendations ( Section 20 (5) SGB V).

According to the case law of the Federal Social Court, resident contract doctors are not allowed to close their practices in order to exert pressure on health insurers and statutory health insurance associations to increase the remuneration of contract medical services by refusing to treat the insured ("doctor's strike").

history

In 1883 statutory health insurances were introduced to supply the population. It was up to the health insurances to decide with how many and with which doctors they concluded contracts. In this way , they ensured outpatient medical care for their insured persons .

On the initiative of the Leipzig doctor Hermann Hartmann , the Association of Doctors in Germany was founded on September 13, 1900 to protect their economic interests (Leipzig Association, today: Hartmannbund ) and the dominance of the health insurance companies was questioned and fought against, among other things through strike measures .

In 1913, under state pressure, the Berlin Agreement was signed between the Leipzig Association and the large cash associations, which is considered the predecessor of the security order. The medical profession was given a say in the approval of statutory health insurance physicians.

With the “Fourth Ordinance of the Reich President for Securing Economy and Finances and for the Protection of Internal Peace” of December 8, 1931, the government regulated the “statutory health insurance”. So the physicians' associations were founded that a total remuneration received, she collective agreement could negotiate. In return, they took on the security mandate for the entire outpatient care (although without the mandate to ensure medical care for the insured being explicitly stipulated in the wording of the law), and were given the right to plan the needs of the outpatient sector. There was a clear separation between the outpatient and inpatient sectors.

Through the "Law on Kassenarzt Law" (GKar) of 1955, the doctors' associations and received National Association of Statutory Health Insurance Physicians finally express the freezing order. Section 368n (1) sentence 1 of the Reich Insurance Code in the version of the GKAR read:

"The Association of Statutory Health Insurance Physicians and the National Associations of Statutory Health Insurance Physicians have to ensure the medical care incumbent upon the health insurance companies in accordance with Section 182 and guarantee to the health insurance companies and their associations that the statutory and contractual requirements are met by the statutory and contractual requirements."

As a result, the system of statutory health insurance physicians was reinstalled as “public corporations” . The requirement planning was handed over to the medical self-administration, but the doctors waived strike and combat measures and submitted to arbitration before the regional arbitration office if they could not agree on a remuneration with the health insurance companies .

In 1989, statutory health insurance law was transferred to SGB V and the security mandate was taken over.

In the reforms of the Statutory Health Insurance Physician Act that began in 1955 and later the SGB V, the undivided guarantee was gradually limited by § 118 , § 140 , § 115b , § 116b , § 73b and § 73c and no longer corresponds to the initial situation.

The former monopoly position of the resident doctors and the Association of Statutory Health Insurance Physicians has now changed. Especially since 1993 there have been breaches of the security mandate, often in favor of the hospitals. The most important breakthroughs are:

  • Pre- and post-inpatient treatment (Section 115a SGB V) and outpatient operations and interventions to replace the ward (Section 115b SGB V), which have been possible in hospitals since 1993 with the Health Structure Act (GSG),
  • the integrated care in the version since the GKV Modernization Act (GMG) 2004,
  • the GP-centered care according to § 73b SGB V as amended since the SHI Competition Enhancement Act (GKV-WSG) 2007
  • the special outpatient medical care according to § 73c SGB V in the version since the GKV-WSG 2007,
  • Outpatient care by approved hospitals according to Section 116b (2) SGB V since the GKV-WSG,
  • outpatient specialist medical care according to § 116b SGB V i. d. F. according to the GKV supply structure law (GKV-VStG), which is also possible for approved hospitals in addition to the doctors and facilities participating in statutory health care.

In addition, there is the abandonment of the postulate of outpatient treatment of the insured by freelance doctors or psychotherapists. This shows not only the introduction of the medical care centers (MVZ) as such, but also the fact that in addition to contract doctors and contract psychotherapists, among other things, hospitals can also set up MVZs.

Austria

Social Insurance Act

In Austria, according to Section 84a of the General Social Insurance Act (ASVG), the main association of Austrian social insurance institutions and the individual social insurance institutions are the addressees of a mandate to ensure the long-term supply of insured persons, taking into account scientific (in particular health-economic) findings by working on a cross-regional and cross-sectoral project Participate in the planning, control and financing of the health system. The results agreed in the Federal Health Commission are to be implemented through a coordinated approach to care for the insured with the aim of optimizing the use of funds.

Federal Tax Code

According to section 232 of the Federal Fiscal Code (BAO), the tax authority can, as soon as the offense to which the tax regulations link the tax obligation, even before the extent of the tax liability has been determined, until the enforceability of section 226 BAO has occurred, issue a security order to the taxable person in order to to counter a risk or substantial impediment to the collection of the fee.

literature

  • Aaron Bogan: The security order of the statutory health insurance associations. At the same time, an analysis of the effects of selective contract care structures on the statutory health insurance architecture . Writings on social law, Volume 20. Nomos-Verlag, 2012. ISBN 978-3-8329-7316-2 . Nomos eLibrary

Web links

Individual evidence

  1. BSGE 98, 294, 304
  2. Becker, Kingreen: SGB ​​V, 6th edition. 2018, § 72 marginal no. 2, 3
  3. Federal Shell Agreement - Doctors from August 31, 2019 PDF, 359 KB
  4. Becker, Kingreen: SGB ​​V, 6th edition. 2018, § 75 marginal no. 7, § 95 No. 6th
  5. Becker, Kingreen: SGB ​​V, 6th edition. 2018, § 95 marginal no. 7th
  6. BVerfG, decision of March 20, 2001 - 1 BvR 491/96 para. 3, 38 ff .; BSG, SozR 3-2500 § 13 No. 4
  7. Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 30 f .; JurisPK / Hesral, SGB V, § 75 No. 38 ff.
  8. Becker, Kingreen: SGB ​​V, 6th edition. 2018, § 75 marginal no. 9
  9. Ordinance on the granting of curative care for law enforcement officers in the Federal Police (Bundespolizei-Heilfürsorgeverordnung - BPolHfV) of May 22, 2014 (Federal Law Gazette I p. 586), which is amended by Article 12 of the Act of July 17, 2015 (Federal Law Gazette I P. 1368) has been changed
  10. Feest, Lesting: Prison Act, Before Section 56, Rn. 3
  11. Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 28
  12. BR-Drs. 755/06, p. 319; BT-Drs. 17/4782, p. 8
  13. Eichenhofer, Koppenfeld-Spies, Wenner: Commentary on the Social Security Code V, 3rd edition 2018, § 75 no. 24; Sodan / Sodan: Handbook of Health Insurance Law, Section 45 No. 34
  14. Own establishment of a health insurance website of the AOK Federal Association , accessed on October 9, 2019
  15. National survey of the KBV on the security order website of the KBV, accessed on October 9, 2019
  16. Bureaucracy Index 2017: The burden in medical practices has increased slightly. KBV website, accessed on October 9, 2019
  17. Prevention recommendations Form for recommending behavior-related primary prevention. KBV website, accessed on October 9, 2019
  18. BSG, judgment of November 30, 2016, B 6 KA 38/15 R
  19. On the history of the KV system KV Hamburg. Retrieved December 25, 2014.
  20. ^ Chronicle , Hartmannbund. Retrieved December 25, 2014.
  21. Federal Joint Committee: Explanations on outpatient specialist medical care. Retrieved January 17, 2017 .