Status: 25.11.2023, 21:36 PM
By: Sebastian Hölzle
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Apparently, mistakes often occur in the classification of care levels: If those affected object to the nursing report of the Medical Service, they are successful in almost 30 percent of cases.
Munich - If you have relatives in need of care and would like the person concerned to be classified in a care level, you can have an expert opinion drawn up. However, as an evaluation by the ARD political magazine Report Mainz shows, these reports are often flawed. In many cases, it is therefore worthwhile to file an objection. If they are classified in a higher level of care, those affected are significantly more entitled to cash and non-cash benefits.
Where can I apply for the degree of care?
Care benefits must be applied for at the long-term care insurance fund, according to the experts at the consumer advice centres. "To do this, contact your health insurance company, that's where the long-term care insurance company is located." A phone call, an e-mail or a short letter is all it takes. "If, for example, the person in need of care is insured with the AOK, it is sufficient to send the application to the AOK and indicate that it is to be passed on to the long-term care insurance fund." Once the application has been received by the long-term care insurance fund, it will return a form.
What do I need to consider when filling out the form?
Since filling out the form is complicated, it can be useful to seek help. "Everyone has the right to advice: The long-term care insurance fund is obliged to name a contact person within two weeks of submitting the application," explain the consumer advocates. Those affected can also contact the care counselling centre at any time.
What happens after the form has been sent and the level of care has been applied for?
In this case, the long-term care insurance fund instructs the Medical Service (MD) to determine the need for care of the person concerned. In concrete terms, this means that an assessor comes to the house to get an idea of the degree of need for care. The date is usually announced well in advance. For example, the mobility of the person concerned, psychological problems, cognitive and communication skills as well as coping with everyday life are examined.
Can relatives prepare for the appointment of the assessor?
Yes. One is to collect important documents, for example about the course of the disease so far. And those in need of care themselves should prepare themselves internally for a situation that may be unpleasant for them. "In some cases, the assessment situation of those in need of care is perceived as unusual," warn consumer advocates. Those affected would have to demonstrate that they can no longer carry out certain everyday activities independently. The reviewer's questions could therefore be perceived as embarrassing or unpleasant, as they also deal with topics that one rarely discusses with strangers.
A nurse measures a patient's blood pressure. © Andreas Arnold / dpa
It is also important to note that the appointment for an expert is not an exam situation like in school. It's not about doing as well as possible. "Sometimes the care situation is presented in a very embellished way on the part of the person in need of care," consumer advocates have observed. The reason may be shame or a faulty self-assessment. "This can be the case, for example, if a person with dementia has the wrong image of themselves that they can still take care of themselves very well on their own." If this happens, relatives should intervene. You can realistically describe the loss of skills and independence. A one-on-one conversation with the expert can also be helpful here, is the tip of the consumer advocates.
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Is it possible to portray the situation of a person in need of care as worse than it actually is?
Consumer advocates explicitly advise against such acting. Experts are experienced and are quick to determine if the situation is portrayed worse than it actually is. Advice from consumer advocates: "Remain credible and show the actual condition of the person in need of care."
What happens next?
In the next step, the assessor informs the nursing care fund of the result of the assessment as a recommendation. "On the basis of the recommendation of the Medical Service (MD) in the expert opinion, the long-term care insurance company decides on the degree of care," according to the consumer advocates. Those affected receive mail and find out whether the application for the care degree has been approved or rejected.
How should those affected react if the application has been rejected or the desired level of care has not been approved?
According to the consumer advice centres, those affected have one month after receipt of the decision to lodge an objection with the nursing care insurance fund – preferably by registered letter with acknowledgement of receipt. Then it all starts all over again: "In the appeal procedure, the long-term care insurance company reviews its decision again and a second opinion is usually prepared," according to the consumer advice centres. Either this expert opinion is carried out on the basis of the documents or with a new visit to the person in need of care.
Is it worth the effort?
In many cases, the answer is unequivocal. The success rate is extremely high, as figures published yesterday by the ARD political magazine Report Mainz show. According to the report, a total of 2022.2 million nursing reports were prepared by the medical services in 5. In 185,000 cases, appeals were lodged – and in many cases successfully. Almost 55,000 times the level of care had to be corrected "in the same situation", it said, i.e. in almost 30 percent of all objection reports. As a result, people in need of care are often classified into care levels that are too low and do not receive the financial benefits to which they are entitled.
Those affected are "left out in the rain because care assessments are not carried out correctly," the magazine quoted Katharina Lorenz from the Social Association of Germany (SoVD) Lower Saxony. The expert estimates that the number of unreported cases is significantly higher. Of the total of 2.5 million nursing reports in 2022, only less than eight percent of the cases were appealed. Lorenz justifies the low objection rate with the fact that the decision is usually accepted by those affected because they simply no longer have the strength to initiate objection proceedings.
And what can those affected do if the appeal was not successful after all?
"If the objection does not bring the desired result, those affected still have the option of going to the social court," says the consumer advice centres. In the vast majority of cases, court costs were not incurred before the Social Court. And if the proceedings are in favour of the person in need of care, the patient's own legal fees would be covered by the long-term care fund. In order to further increase the chances of direct acceptance, it is also worthwhile to pay attention to certain things and avoid common mistakes. You can find out what these are and how they can harm you here.