Statutory insurance, treated as a patient: possible, but you should know the gaps
Created: 12/24/2022, 10:00 am
By: Dieter Tannert
Legally insured but treated like a private patient?
Possible - through the reimbursement procedure of the statutory health insurance companies.
In Germany there is an obligation to have health insurance.
The general case for employees is health insurance in a statutory health insurance company.
If an employee earns at least 64,350 euros per year (as of 2022), they can choose private health insurance.
Difference between private and statutory insurance
In the case of privately insured persons, the treating doctor can regularly demand a higher fee, since he is not bound to the amounts negotiated with the statutory health insurance companies, but can fall back on an existing fee schedule for doctors (GÖA).
According to a publication by the association of private health insurance companies, 12.7 percent of the population in Bavaria is privately insured.
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Reimbursement can be chosen from the statutory health insurance
But even if you have statutory health insurance, you can be treated as a private patient at a doctor's appointment.
To do this, enter this status when making an appointment.
Of course, you are then obliged to pay the doctor's higher fee.
However, the statutory health insurance can participate in this, provided that the principle of cost reimbursement has been agreed with your health insurance company beforehand.
Reimbursement gaps are possible in the reimbursement of costs
However, the health insurance company only reimburses the amount that belongs to the catalog of benefits of the statutory health insurance companies.
The benefit amount is laid down in the "Uniform Assessment Scale" and can be found on the Internet.
Since the statutory health insurance companies only have to pay lower amounts than a doctor is allowed to calculate according to the GOÄ, there are reimbursement gaps that the insured person has to bear himself.
According to a study by the Scientific Institute for Health Economics and Health System Research, the amount that the doctor can bill according to the GOÄ is on average 2.3 times higher than the amount that the health insurance company reimburses.
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For example, a family doctor can charge EUR 58.99 for a medical consultation according to the GOÄ, while the health insurance companies only charge an amount of EUR 34.63 for reimbursement.
An exemplary examination of a 50-year-old man with upper abdominal complaints leads to a reimbursement amount of 46.48 euros from the health insurance company, while according to the GOÄ an amount of 149.24 euros can be calculated by the doctor.
However, gaps in reimbursement can be insured
As the trend towards giving one's own health a great deal of leeway, including financial ones, was recognized by insurance companies, there are now a number of providers who can insure the reimbursement gap (e.g. ARAG, Tariff 182).
How to get your money back: The reimbursement procedure
If you want to use the reimbursement procedure, you must have declared this to the health insurance company beforehand.
By choosing this tariff, the policyholder is bound to this form of accounting for at least three months.
The choice of reimbursement can be made for all services or for one or more of the following service areas:
Outpatient medical care with psychotherapeutic treatment
Outpatient dental care with orthodontic treatment and dentures
inpatient care
medicines or remedies
After the treatment, the private bill is submitted to the health insurance company for reimbursement.
The health insurance companies may retain up to 5 percent of the reimbursement amount for processing the reimbursement.
Get advice before deciding on the reimbursement procedure
Sascha Straub from the Bavarian consumer advice center advises getting thorough advice from your health insurance company before deciding on reimbursement.
The health insurance experts at the consumer advice centers would also be happy to provide advice.