Bills, Claims & Billing

GKV Billing: The Sachleistungsprinzip

If you're publicly insured in GKV, you benefit from the Sachleistungsprinzip (benefits-in-kind principle). This means you show your Gesundheitskarte (health card) at the doctor's office, receive treatment, and the doctor bills your Krankenkasse directly. You rarely see a bill at all.

Behind the scenes, your doctor uses the EBM (Einheitlicher Bewertungsmaßstab) — the standardized billing catalog for public insurance. Every medical service has an EBM code with a point value, and these points are converted into euros each quarter based on the Orientierungspunktwert set by the Bewertungsausschuss. Doctors submit their billing to the Kassenärztliche Vereinigung (KV), which aggregates and settles with the Krankenkassen.

As a GKV patient, you can request a Patientenquittung — an itemized statement of all services billed on your behalf. Under §305 SGB V, your Krankenkasse must provide this (usually free once per quarter, small fee after that). It's a useful tool for verifying what your doctor actually billed, especially if something feels off.

PKV Billing: The GOÄ Fee Schedule

Private insurance operates on the Kostenerstattungsprinzip (cost-reimbursement principle). You receive treatment, the doctor sends you a bill, you pay it, and then submit the invoice to your PKV insurer for reimbursement. This is fundamentally different from GKV.

Doctors billing private patients use the GOÄ (Gebührenordnung für Ärzte) — the official fee schedule for physicians. The GOÄ dates back to 1982 (with the last major update in 1996) and lists every medical service with a base fee. Unlike the EBM, doctors can apply a Steigerungsfaktor (multiplier) to each service:

• 1.0x (Einfachsatz): The base rate — rarely charged in practice
• 2.3x (Regelhöchstsatz): The standard maximum for most services. Anything up to 2.3x requires no special justification.
• Above 2.3x up to 3.5x: Allowed, but the doctor must provide a written justification (Begründung) on the invoice explaining the increased difficulty, time, or complexity
• Above 3.5x: Only permissible if the patient agrees in writing beforehand (Honorarvereinbarung nach §2 GOÄ). This is rare and your PKV will almost never reimburse above 3.5x.

For dental procedures, the equivalent fee schedule is the GOZ (Gebührenordnung für Zahnärzte). The GOZ works similarly to the GOÄ with Steigerungsfaktoren, but the standard maximum (Schwellenwert) for most dental services is 2.3x, and the upper limit is 3.5x with justification.

Reading a GOÄ Invoice

Understanding your doctor's invoice (Arztrechnung) is essential for PKV patients. Here's what you'll see on a typical GOÄ-based bill:

• Rechnungsnummer: The invoice number — keep this for your records and PKV submission
• Datum der Leistungserbringung: The date(s) when services were rendered
• GOÄ-Ziffer (or GOÄ-Nr.): The specific GOÄ code for each service. For example, GOÄ 1 = consultation, GOÄ 5 = physical examination, GOÄ 250 = blood draw
• Leistungsbeschreibung: Text description of the service
• Steigerungssatz: The multiplier applied (e.g., 2.3x, 1.8x, 3.0x)
• Begründung: If the multiplier exceeds 2.3x (or 1.8x for technical services), a written justification must appear
• Einzelbetrag: The fee for each line item (base rate × multiplier)
• Gesamtbetrag: Total amount due
• Zahlungsfrist: Payment deadline (typically 30 days)

How to verify your charges

You can look up any GOÄ-Ziffer online to confirm the base rate. Multiply it by the stated Steigerungssatz and check if the Einzelbetrag is correct. Watch for these common billing errors:

• Services not rendered: Check that every listed procedure actually happened during your visit
• Duplicate billing: The same service billed twice
• Analog billing (Analogbewertung): For services not in the GOÄ, doctors may bill "analogous" to a similar listed service — marked with an "A" or "analog." This is legal but should be reasonable.
• Missing justification: Any multiplier above 2.3x (or 1.8x for technical/lab services) without a written Begründung is formally incorrect
• Zielleistungsprinzip violations: Certain services include sub-services that shouldn't be billed separately

PKV Reimbursement Process

Submitting bills to your private insurer is straightforward but requires diligence:

1. Pay the doctor's bill within the stated payment period (usually 30 days). You are legally the debtor, regardless of what your PKV decides.
2. Submit the invoice to your PKV. Most insurers now offer three methods: a smartphone app (photo or scan of the invoice), an online portal (upload PDF), or traditional mail (send original or copy).
3. Processing time: Expect 1-4 weeks for straightforward claims. Complex or high-value claims may take longer if the insurer requests additional documentation (e.g., medical reports, justification letters).
4. Reimbursement: Your PKV reimburses according to your tariff. This may be partial — for example, if your tariff covers GOÄ up to 2.3x but your doctor charged 3.5x, you'll only be reimbursed at the 2.3x rate. Check your Tarifbedingungen carefully.
5. Disagreements: If your PKV denies or reduces a claim, you'll receive a written explanation. You can dispute this (more on that below).

Disputing Medical Bills

If you believe a doctor's bill is incorrect or excessive, you have several avenues:

1. Talk to the practice first: Contact the Praxis directly. Billing errors are common, and many are resolved with a simple phone call to the Abrechnungsstelle (billing office). Ask for an itemized explanation of any charges you don't understand.
2. Check the Steigerungsfaktor: If the multiplier exceeds 2.3x without adequate justification, you can formally object. The doctor must either provide a proper Begründung or reduce the charge.
3. Contact your PKV: Your insurer has billing experts who review GOÄ charges. If they identify overcharging, they'll support your dispute and may handle communication with the doctor.
4. Ärztekammer (State Medical Chamber): File a complaint with your regional Ärztekammer. They can review the bill for GOÄ compliance and mediate between you and the doctor.
5. Bundesärztekammer mediation: For more complex disputes, the Bundesärztekammer offers mediation services. This is non-binding but carries significant weight.
6. Legal action: As a last resort, you can take the matter to court. For amounts under €5,000, the Amtsgericht handles the case. Consider a Fachanwalt für Medizinrecht (specialist medical lawyer) for complex cases.

IGeL Billing (Individual Health Services)

IGeL (Individuelle Gesundheitsleistungen) are medical services not covered by GKV that doctors offer for an out-of-pocket fee. These include things like travel vaccinations, certain screening tests, or cosmetic procedures.

Strict rules apply to IGeL billing:

• Separate from Kassen billing: IGeL services must be clearly separated from GKV-covered services. A doctor cannot bill the Kasse for the consultation and then charge you separately for an IGeL performed during the same visit without clear delineation.
• Written agreement required (§12 GOÄ): Before any IGeL service, the doctor must provide a written agreement (schriftliche Vereinbarung) that lists the service, the expected cost, and confirms you consent to paying out of pocket. Without this signed agreement, you are not obligated to pay.
• GOÄ-based billing: IGeL must be billed according to the GOÄ, not at arbitrary prices. The Steigerungsfaktor rules apply.
• Your right to decline: You can always say no. Doctors must not pressure you, and declining an IGeL must not affect the quality of your GKV-covered care.
• Verify legitimacy: Check the IGeL-Monitor (igel-monitor.de) by the MDS (Medizinischer Dienst) to see evidence-based evaluations of common IGeL services. Many are rated "unklar" (unclear benefit) or "negativ" (no proven benefit).

Hospital Billing

Hospital billing in Germany works differently from outpatient care and uses the DRG system (Diagnosis Related Groups), known in German as Fallpauschalen. Each hospital stay is classified into a DRG based on the diagnosis, procedures performed, severity, and complications. The hospital receives a fixed payment per case, regardless of the actual length of stay (within defined boundaries).

For GKV patients, the hospital bills the Krankenkasse directly. You only pay the statutory co-payment of €10 per day for a maximum of 28 days per calendar year. Beyond that, there's no additional cost for standard care in a shared room with the assigned ward doctor.

For PKV patients (or GKV patients with supplementary hospital insurance), additional charges may apply for Wahlleistungen (elective services):

• Chefarztbehandlung: Treatment by the chief physician. Billed separately according to the GOÄ, often at higher Steigerungsfaktoren.
• Ein- oder Zweibettzimmer: Single or double room instead of the standard multi-bed room. Daily surcharges of €50-200+ depending on the hospital.
• Wahlleistungsvereinbarung: Before receiving any Wahlleistungen, you must sign a written agreement. This is mandatory — without it, the hospital cannot charge you for extras. Read it carefully: it commits you to paying even if your PKV doesn't fully reimburse.

Checking your hospital bill

Hospital bills can be complex. Request an itemized invoice (detaillierte Rechnung) and verify:

• Correct admission and discharge dates
• Accurate DRG coding (misclassification is not uncommon)
• That Wahlleistungen you agreed to match what was actually provided
• Chefarzt charges correspond to actual treatment by the Chefarzt (not a deputy or Oberarzt)
• Room charges match the type of room you actually had

Co-payment Tracking (Zuzahlungsbefreiung)

GKV patients pay co-payments (Zuzahlungen) for prescriptions, hospital stays, medical aids, and some therapies. However, there's an annual cap — the Belastungsgrenze:

• Standard cap: 2% of your gross household income per calendar year
• Chronically ill: 1% of gross household income (requires certification from your doctor)
• Income calculation: Gross income minus Freibeträge — €6,363 per year for the first household member, €4,536 for each additional adult, €8,952 per child (2024 figures, adjusted annually)

Once you hit the cap, you can apply for a Zuzahlungsbefreiung (exemption certificate) from your Krankenkasse. For the rest of the calendar year, you pay no more co-payments. To do this:

1. Keep every receipt: Collect all Zuzahlung receipts (prescriptions, hospital, therapies, medical aids, transport)
2. Calculate your threshold: Based on your household income and family size
3. Submit to your Kasse: Send copies of all receipts along with proof of income. Many Kassen have a dedicated form (Antrag auf Zuzahlungsbefreiung).
4. Receive your certificate: Once approved, you get a Befreiungsausweis valid for the rest of the year. Show it whenever co-payments would apply.
5. Pre-pay option: If you know you'll hit the cap, some Kassen let you pay the full 2%/1% upfront in January and receive immediate exemption for the entire year.

Pharmacy Bills

When you fill a prescription at a German pharmacy (Apotheke), you typically pay a Zuzahlung of €5-10 per medication (10% of the drug price, minimum €5, maximum €10). There are a few nuances to understand:

• Zuzahlung receipts: Always ask for and keep the Zuzahlungsquittung (co-payment receipt). You need these for your annual Zuzahlungsbefreiung calculation and for tax purposes.
• Rabattverträge: Your Krankenkasse has discount contracts (Rabattverträge) with specific pharmaceutical manufacturers. The pharmacy must dispense the Rabattvertrag drug even if your doctor prescribed a different brand — unless the doctor explicitly marks "aut idem" on the prescription to prevent substitution. The Zuzahlung may vary depending on the drug supplied.
• Festbetrag (reference price): The Kasse sets a Festbetrag — the maximum it will pay for a given drug category. If your prescribed medication costs more than the Festbetrag, you pay the Zuzahlung plus the difference (Aufzahlung). Ask your doctor for a Festbetrag-compliant alternative to avoid this extra cost.
• Zuzahlungsbefreit drugs: Some medications are priced at least 30% below the Festbetrag and are exempt from Zuzahlung entirely. Your pharmacist can tell you which drugs qualify.

Tax Deductions for Medical Expenses

In Germany, medical expenses that you pay out of pocket can be deducted from your taxable income as außergewöhnliche Belastungen (extraordinary expenses). This applies to both GKV and PKV patients.

What's deductible:

• Co-payments (Zuzahlungen): Prescription co-pays, hospital per-diem charges
• Glasses and contact lenses: Including examination fees if not covered by insurance
• Dental Eigenanteil: Your share of dental prosthetics (crowns, implants, bridges) not covered by GKV or PKV
• Heilpraktiker: Alternative medicine practitioner fees (even if not reimbursed by insurance)
• Physiotherapy co-payments: Your 10% share of physiotherapy, speech therapy, occupational therapy
• Medical aids (Hilfsmittel): Hearing aids, orthopedic shoes, wheelchairs — the portion you pay yourself
• Travel costs to doctors/hospitals: €0.30/km by car, or public transport tickets
• IGeL services: If medically necessary (may require Amtsarzt attestation for contested services)
• PKV premiums: The Basiskrankenversicherung portion is deductible as Sonderausgaben, not as außergewöhnliche Belastungen

The zumutbare Belastung threshold

You can only deduct medical expenses that exceed your zumutbare Belastung (reasonable burden) — a percentage of your total income that depends on your income level, marital status, and number of children:

• Income up to €15,340: 2-5% depending on family status
• Income €15,340-51,130: 3-6%
• Income above €51,130: 4-7%
• Children reduce the percentage — couples with children pay the lowest rate in each bracket

For example, a married couple with two children earning €60,000 might have a zumutbare Belastung of around €1,800-2,400. Only medical expenses exceeding that threshold reduce their taxable income. This is calculated using a tiered method (Stufenberechnung) per a 2015 Bundesfinanzhof ruling, which is more favorable than the old flat-rate method.