The cost reimbursement principle

Since the beginning of 2004, all SHI-insured persons have been free to choose the reimbursement principle (regulated in §13 SGB V).
The restriction to individual subareas "outpatient", "inpatient" or "_dental(dentist)", but also the choice of the cost reimbursement primzops for the areas "prescribed medical services (drugs and dressings), as well as aids" is possible.

The cost-reimbursement principle is basically similar to the procedure used in private health insurance (self-payer and subsequent reimbursement by a payer) and is the counterpart to the common form of billing in statutory health insurance. This should be familiar to all insureds, although perhaps not by title. This is the principle of payment in kind.

Long waiting periods ? NOT , if you are a private patient


Principle of performance in kind

Here, every member of the GKV has an insurance card in contrast to the reimbursement principle, by which he or she identifies himself or herself as insured at the doctor's office. Upon presentation of this card, the insured person receives benefits that are economical, sufficient, necessary and appropriate according to the law (§ 12 SGB -V). It is of course rarely the best medical care, but this is solely dependent on economic viability in relation to all members of the health insurance fund.

Reimbursement principle

In the case of the reimbursement principle, the treatment of the SHI patient is billed as for a private patient (self-payer) according to the official fee schedule for physicians ( GOa ), for dentists ( GOZ ).
He pays his bill directly to the doctor and has the reimbursable portion reimbursed by his health insurance company.
Only the portion that would also have been incurred under the in-kind principle is reimbursable, minus an administrative fee of approx. 5-10 percent.
The legally insured can choose to be billed on a reimbursement basis every quarter (every 3 months as of January, April, July, October) on or off.

As a patient thus circumvents the budgeting of the GKV, he thus receives treatment that he would most likely not have received as a "normal patient".
Since the physician can offer a set of additional treatments and in addition by a multiplication of the GOa – rate a higher amount in calculation may, the amount the legal health insurance takes over will not be sufficient, this better medical supply to finance.

Note: The statutory health insurance itself does not usually provide benefits for treatment by doctors without health insurance approval, but there are very well supplementary insurance, which in this case, even without a GKV -Vorleistung 85% (or even more) of the cost of private doctors cover.

Likewise, the statutory health insurance does not pay for medications that are prescribed privately (green private prescription) within the framework of the cost reimbursement principle. A suitable supplementary outpatient insurance for the reimbursement principle, on the other hand, would definitely pay for medications that are not subsidized by the public health insurance system.

Tips on reimbursement of expenses

When opting for the reimbursement principle, it is strongly advised to take out suitable supplementary outpatient health insurance that covers these differential costs and also pays, for example, if there is no advance payment from the SHI (z.B. in the case of physicians who are not licensed by the statutory health insurance).

For a short time, some statutory health insurers have themselves been offering such supplementary tariffs as elective tariffs. It is strongly discouraged to use them, because in almost all cases they do not reimburse the costs for additional treatments, which the health insurance would not have covered otherwise, and they also do not cover treatments by doctors who are not licensed by the health insurance.

The recommendation therefore clearly goes in the direction of the offers of some private health insurers in this regard.

The person with statutory health insurance can choose reimbursement after having been informed of this by the service provider. Consultation or consent of the statutory health insurance is no longer required.
Some health insurance companies have special forms through which the reimbursement principle is requested.
In this regard, contact the health insurance company for an appropriate form to convert to the *reimbursement principle.
However, you should in no case take advantage of the often very weak rates for the reimbursement principle of health insurance companies, because in the case of treatment by private doctors or if the health insurance company does not pay, you have to reckon with extremely high deductibles if you choose the reimbursement principle in conjunction with a weak supplementary insurance.

Many employees, in ignorance, advise against the choice of the cost reimbursement principle and were even before it. They justify this by saying that supplementary insurances would not pay anyway for services where the SHI does not cover (z.B. with private doctors). However, this is misinformation.
Appropriate rates put you on almost equal footing with a fully PKV-insured person.

We advise you to choose the reimbursement principle only for outpatient treatment, since a good supplementary health insurance policy or a good supplementary dental insurance policy can be used to "upgrade" the benefits-in-kind principle in these areas much more safely and cost-effectively to the insurance level of a private patient.

Here's how to proceed with the cost reimbursement principle:

Correct areas to switch to reimbursement

With most health insurance companies, the reimbursement principle must be applied directly to the health insurance company. There are special forms* for this purpose on which you also have to select the individual areas for which you want to switch to the cost reimbursement principle. (Outpatient medical services, inpatient services, prescribed medical services, assistive devices, dental services). It is important to select only those areas for which you have suitable supplemental health insurance. With those of a supplementary outpatient insurance such as z.B. DKV KAMP should be selected outpatient medical services, prescribed medical services and aids (not hospital, not dentist), with a tariff such as "Arag 182", which does not pay for aids, the uninsured areas should accordingly be left in the benefit in kind principle.
In the case of a complete cost reimbursement principle tariff such as DKV BMG, the cost reimbursement principle can be applied accordingly to all areas incl. the insurance. Hospital and dentist are chosen.
It is important to note that normal supplementary dental insurance or supplementary hospital insurance, which exist in addition to supplementary outpatient insurance for the reimbursement principle, are not suitable for billing according to the reimbursement principle, if you do not have a complete tariff such as the DKV BMG should accordingly not be switched to the reimbursement principle for the dental and hospital sector.
For the service areas that have been converted to the cost reimbursement principle, the GKV insurance card will no longer be relevant and will not work anymore. You are now a self-payer with reimbursement of expenses.

The procedure of treatment and reimbursement

At the doctor's office, you now present yourself as a private patient or, alternatively, as a . insured in the reimbursement principle from.
The doctor issues you a private bill for the treatment according to the scale of charges for physicians ( GOa ).

  • You submit this bill to the SHI, which reimburses your share to your account. Provided that the therapist has a health insurance license, the GKV will reimburse approximately a share of 10-40% of the bill.
  • The rest will be transferred to you by the additional insurance (as far as reimbursable part) after presenting the invoice.
  • From the money received can then easily pay the doctor's bill.
  • The same applies to receipts and invoices from pharmacies or remedies such as physiotherapy or for medical aids.

With the right supplementary insurance, the reimbursement principle is the ideal solution for people with statutory health insurance who, for various reasons, have no choice but to switch to private comprehensive insurance, or for whom switching without the possibility of returning to statutory health insurance later in life is too risky.

Also highly recommended is choosing reimbursement coverage for children, as the appropriate supplemental coverage here is quite affordable, but can provide the child with the highest form of medical coverage possible.

First supplementary insurance then switch to reimbursement principle

We strongly advise you not to switch to the GKV reimbursement procedure until you have successfully taken out suitable supplementary insurance.
For the conclusion of a private health supplementary insurance a health examination and/or. Health questions needed and the application process can take 2-4 weeks in some cases. So the requested insurance start date is best 1-2 months in the future.
Only when the insurer has accepted the application should you send the form for conversion to the reimbursement principle to the statutory health insurance fund.
Otherwise, without a suitable additional insurance, you run the risk of being stuck with a large part of the treatment costs, which are then always billed privately, at least until the next quarter.

Health insurance companies often give incorrect information

Many people who wanted to switch to the reimbursement method and cover themselves by taking out supplementary outpatient insurance like private insurance were given incorrect information about the possible dangers of the switch when they requested the relevant switch forms from their health insurer.
For example, some health insurers are warning that alleged co-payments will remain even if supplemental outpatient insurance is purchased.
This, of course, depends on the chosen tariff!
If you go to a private doctor without supplemental outpatient insurance, you won't get anything from your public health insurance, of course, the health insurance companies don't point this out.
Good outpatient tariffs pay 85%-100% of the bill (DKV KAMP, the tariff DKV BMG even *up to 100%), without the need for advance payment by the health insurance and even worldwide.
This is significantly more than the statutory health insurance in such a case (z.B. would be paid by a private doctor), because they do not reimburse anything.

Because of the increased administrative burden on health insurers, employees of public health insurers like to discourage the choice of the reimbursement procedure.
Don't let this intimidate you, with the right supplementary outpatient insurance all these arguments of the statutory health insurance don't count. In addition, the private tariffs also take over the administrative cost deductions of 5-10%, which the statutory health insurance company retains in the processing of benefits. In the case of advance payment by the GKV, which is usually the case with doctors who are licensed by the GKV, almost all suitable supplementary tariffs reimburse 100% of the remaining costs, without GKV advance payment, depending on the tariff, as much as 60-100%.

Good GKV = easy reimbursement process

In the meantime, there are also health insurance companies that have adapted their service regarding the cost reimbursement principle to the needs of their members and simplify the process significantly.
For example, BIG offers its members not only discounts on the appropriate DKV reimbursement principle, but also takes a lot of work off their shoulders by choosing the reimbursement procedure.
Because bills there are only to be sent to the SHI itself, which after processing and remitting its share to the insured, sends the bill directly to DKV for quick further reimbursement. DKV then reimburses the remainder of the invoice amount, depending on the advance payment from the statutory health insurance fund.

If you are interested in this billing option orgenerally in coverage with choice of reimbursement principle, please contact us.