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 Health Insurance Coverage and Legal Issues:
German Patients |
Privately Insured German PatientsThe days when privately insured patients could assume that their treatment expenses would be covered 100% with no questions asked are over. The insurance industry, like many other industries, has had to react to the current market situation and the collapsing financial markets. A high-ranking employee from an insurance company recently admitted during a television interview that, as insurance companies have suffered significant losses because of the collapsing financial markets, they now have to deal with cost pressures that no longer allow for the reimbursement of "unchecked" invoices.
The first repercussions of this have already become evident. The German Orthopaedist's Association(1) is currently accusing the German postal workers' state health insurance company(2) of arbitrarily striking items with fixed charges(3) as stipulated by German Charges Catalogue for Physicians(4) from invoices sent in for reimbursement. "That occurred senselessly and randomly and across the country", complained Dr. Nils Graf Steenbock, Chairman of the German Orthopaedist's Association (as quoted in "Orthopaedische Nachricht", 08/02).
1) German Orthopaedist's Association = Deutsche Orthopaedenverband
2) German postal workers' state health insurance company = Postbeamtenkrankenkasse
3) items with fixed charges = Gebuehrenziffern
4) German Charges Catalogue for Physicians = Gebuehrenordnung für Aerzte/GOAE
Criticism of these inadequate reimbursement policies is not only coming only from the German Patient Protection Federation(5). Dr. Heribert Knechten, chairman of DAGNAE(6), expressed his thoughts on the German television program "plusminus" as follows: "I'm a representative of DAGNAE and therefore also of the specialist practices(7) in Germany. All over Germany, we are basically seeing a lot of cases like this - especially with the DKV(8). They are causing massive problems, while other insurance companies and health insurance companies aren't doing that at all. For our part, we have years of experience in dealing with HIV and AIDS. And it simply isn't possible for us to regulate our experiences with this disease pattern, which is still a very new one, down to the minimal standard the DKV wants us to. I believe that it is very important that our quality standards remain high."
5) German Patient Protection Federation = Patientenschutzbund
6) Consortium of German Doctors with a Practice that Treat HIV-infected Patients = Deutsche Arbeitsgemeinschaft niedergelassener Ärzte in der Versorgung HIV-Infizierter
7) specialist practices = Schwerpunktpraxen
8) DVK = Deutsche Krankenversicherung, a German health insurance company
Bearing this development in mind, it is not possible to accurately predict to what level private health insurers will reimburse costs. The fact is that there are health insurance companies that value high quality services and therefore cover the costs incurred at the Alpha Klinik because they are convinced of our outstanding performance level. On the other hand, there are also insurance companies that approach things from a more cost-oriented perspective and try to - regardless of the quality of service - pare down invoices or keep reimbursements as low as possible. |
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In any case, we recommend that you request a cost estimate from the Alpha Klinik and pass it on to your health insurance company. |
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Privately Insured German Patients Entitled to Subsidies(9)9) subsidy entitlement = Beihilfeberechtigung
Services from a private clinic do, as a rule, qualify for subsidised coverage. However, please note that a direct, subsidised coverage of the costs that Alpha Klinik invoice is not possible.
German state-specific subsidy regulations contain a regulation under which costs are reimbursable that would have been incurred if the treatment would have been performed in a comparable public hospital. Generally, university clinics are used as the basis for comparison. The cost level determined at this basis will definitely be reimbursed by the state subsidy organisations(10). However, please note that another regulation exists for the country-wide subsidy organisations(11).
10) state subsidy organisations = Landesbeihilfestellen
11) country-wide subsidy organisations = Bundesbeihilfestellen |
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State-insured German Patients with a Private Supplementary Insurance(12)
12) private supplementary insurance = private Zusatzversicherung
Within this insurance constellation, payment by the private supplementary insurance company depends very much on the individual insurance contracts. There are supplementary insurance policies that, regardless of whether the patient's state insurance also offers coverage, will definitely cover the clinic costs completely.
However, for all other patients with supplementary private insurance, a deliberate gap exists in the regulations that apply to treatment at a private clinic. If coverage by the supplementary insurance company depends on whether the state insurance pays, it should be noted that state insurance plans cannot cover costs incurred at the Alpha Klinik, because the Alpha Klinik is not included in any state hospital requirement plan(13) and is therefore not a hospital under contract to the state health insurance associations(14).
13) state hospital requirement plan = Bedarfsplan
14) hospital under contract to the state health insurance associations = Vertragskrankenhaus |
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German Patients with State Insurance
In general, state health insurance organisations are not required to cover the costs of treatment at Alpha Klinik, since Alpha is not a hospital under contract to the state health insurance associations(15) and the Alpha physicians are not under contract to the state health insurance associations(16) either. In this respect, the Alpha Klinik is not integrated into the state insurance system.
15) hospital under contract to the state health insurance associations = Vertragskrankenhaus
16) doctors/physicians under contract to the state health insurance associations = Vertragsaerzte
This does not mean, however, that payment is not possible under any circumstances. Our experience shows that, in many cases, individuals with state insurance receive goodwill payments from their health insurance companies. And in some exceptional cases, if the operation is not offered under state physician care(17), a patient with state insurance can even be entitled to treatment at the Alpha Klinik.
17) state physician care = vertragsärztliche Versorgung |
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