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Reimbursement for those with statutory health insurance

The fifth book of the Social Code regulates the reimbursement of costs for statutory health insurance holders in private practices (Section 13 (5) SGBV). This is intended to address the injustice that people with mental illnesses often have to wait months for a therapy appointment. Statutory health insurance funds are mandated to guarantee comprehensive, needs-based, and local care for their insured members. If this target is not met (e.g., if the waiting time for an appointment is unreasonable, usually more than three months), statutory health insurance must, upon request, cover the entire cost of private medical treatment, provided that the care is provided promptly and with the same qualifications as a doctor or psychologist approved by the health insurance fund (license to practice, proof of specialist knowledge, entry in the medical register, etc.).

 

To ensure that the insured person's reimbursement application is approved, the Federal Chamber of Psychotherapists provides important information that patients should consider beforehand. On this page, I have compiled information to help you complete these formalities. Of course, you can also contact me at any time if you have any questions.

Step 1

Try to get an appointment at a practice that is approved by the health insurance company.

 

  • First, you should call several approved therapists near your home and try to secure a therapy appointment as soon as possible. A list of approved therapists can be found at the Bavarian Association of Statutory Health Insurance Physicians . If you receive an appointment as soon as possible, take it.

  • Otherwise, please document the date and time of your request, the therapist's name and address, and when you were offered an appointment. You can download the application form for this purpose, where you can also document your attempts to request a consultation.

  • In addition, you should make at least one appointment for a psychotherapy consultation with a health insurance-approved therapist. Since April 1, 2017, all health insurance-approved therapists have been required to offer a weekly consultation hour, which you can attend without prior appointment. Please also document this visit and the results of your efforts.

Step 2

Make an appointment at my practice and come for an initial consultation.

 

  • If you have not been able to get an appointment with at least 3-5 health insurance-approved therapists, have had to wait more than three months for one, or if treatment is extremely urgent and your health insurance company has not been able to find you a place for therapy, please make an appointment (initial consultation) at my practice and bring with you the documentation of your unsuccessful appointments.

  • In an initial consultation, the need for psychotherapy will be determined. If this is the case, you will receive confirmation from me that your treatment is medically necessary and that, as a specialist in psychiatry and psychotherapy, I can provide it promptly.

  • If you already have a so-called consultation report from your family doctor or a specialist, please feel free to bring it with you. Otherwise, it helps if you bring a recent routine lab report. Before starting psychotherapy, it should be ruled out whether there are any physical illnesses that would preclude it (this is required before starting any psychotherapy). Since I am a specialist myself, a separate consultation report is generally not necessary to apply for psychotherapy with me.

Step 3

Submit all documents to your health insurance provider!

 

  • Please send all documents (1. your application , 2. my certificate of necessity, 3. any medical report) to your health insurance provider promptly. The application must always be submitted by you before starting psychotherapy.

  • You have the right to receive a decision from your health insurance company within three weeks of receipt. If an expert assessment is necessary, this period is extended to five weeks. If this period expires without justification, the treatment is considered approved.

  • You can wait to start until you receive a positive decision, or you can begin your lessons beforehand. However, the costs will only be covered if your health insurance provider approves your application; if your application is rejected, you have the right to appeal.

  • You will receive an invoice from me approximately once a month, which you must pay within the specified deadline. You submit this invoice to your health insurance provider, and the costs incurred are reimbursed to your account ("reimbursement"). This means that I will not bill you directly to your insurance card, as you are usually used to.

  • The therapy you purchased yourself is private treatment, meaning your health insurance provider is not permitted to reduce the benefits to the statutory rate, but must cover the private medical rate. Nevertheless, it is often common practice for bills to be reduced to the statutory rate, thus leaving a deductible. You can also object to this.

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Danke für Ihre Nachricht!

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