Out-Patient Reimbursement

Executive Summary

• For out-patients, new therapies are eligible for statutory health insurance which funds reimbursement only after testing and licensing
• The reimbursement of out-patient services in Germany is based on physician fee schedules
  • The fee schedule for the SHI (Statutory Health Insurance) is named EBM (“einheitlicher Bewertungsmaßstab”) and an inclusion of a new diagnosis & therapy method requires a positive voting from the G-BA
  • Where a medical device is being used at home by a patient, it must be included in the therapeutic appliance schedule in order to be reimbursable
  • The fee schedule for Private health insurance is named GOÄ (“Gebührenordnung für Arzte”) and an application for the inclusion of a new diagnosis or therapy method will need to be made to the German Medical Association
• If the application for the inclusion in fee schedules fails, there are other options including:
  • IGeL (Individuelle GesundheitsLeistungen) inclusion and selective contracts
  • Obtaining reimbursement by single SHI funds is to negotiate selective contracts with local health insurances