How can I bill panel patients in a private practice?

What is the cost reimbursement process?

Through the cost reimbursement procedure, a person who is unable to find a psychotherapy place in the standard care system within the next three months can apply for cost reimbursement from his/her own statutory health insurance and, after approval, begin therapy with a private psychotherapist:in. In other words, according to § 13.3 SGB V: The statutory health insurance is required to cover the costs of treatment in a private practice if no therapy place can be offered within a reasonable time frame (3 months) with a contracted therapist.

What is needed?

In summary, the following four documents are required for the application:

● A formal cover letter.

● a medical certificate stating that psychotherapeutic treatment is necessary and cannot be postponed.

● A record of unsuccessful search for a panel psychotherapist:in.

● A certificate from a psychotherapist in private practice that the treatment can be taken over at short notice (waiting period less than three months).

These four aspects are briefly explained below.

1. the formal cover letter could look like this

Sample cover letter to the health insurance company:

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Address of the insured person

Address of the health insurance company

Place, date

Insured person number

Application for outpatient psychotherapy and reimbursement of costs according to § 13 paragraph 3 SGB V

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Dear Sir or Madam,

I hereby request that you cover the costs incurred by me as a result of outpatient psychotherapy with Ms/Mr ... and assure me that you will do so. Ms/Mr ... is a licensed psychotherapist in a guideline procedure, but is not licensed for statutory health insurance. As you can see from my enclosed protocol, I have tried several times in vain to find a psychotherapist who is licensed by the statutory health insurance who can treat me in a timely manner. My search for a psychotherapist resulted in me having to wait more than ... months for a first appointment. On the other hand, there is a possibility that I could start treatment with Ms./Mr. ... at short notice. I enclose a certificate to this effect. I also enclose a certificate from a [family doctor/specialist/psychotherapist] who considers outpatient psychotherapy to be urgently necessary. If you do not agree to my application, please inform me - as soon as possible - of a licensed psychotherapist in the vicinity of my place of residence with whom I can obtain an appointment at short notice.

I would ask you to process my application as quickly as possible and would like to draw your attention to the deadline set out in Section 13 (3a) of the German Social Code, Book V.

With kind regards

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2. in the cover letter must also be attached a certificate of necessity and non-deferrability of treatment.

This can be issued by a family doctor, psychotherapist, psychiatrist or other specialist. It should be noted that the statutory health insurance companies prefer a medical certificate. We therefore recommend that you obtain a certificate from your family doctor, psychiatrist or other specialist. An additional certificate from the psychotherapist is desirable. For example, PTV 11, which is issued after each consultation with a psychotherapist, could be used here. The PTV 11 should indicate the urgency of the treatment and whether it cannot be postponed, e.g. on the basis of suspected or confirmed diagnoses. In addition, it can be stated which procedure the psychotherapist considers useful. This aspect should be discussed in detail with the patient.

3. in addition, a record of the unsuccessful search for a licensed psychotherapist must be attached to the application.

For this purpose, psychotherapists in the vicinity of the place of residence should be contacted. A list of licensed psychotherapists can be found, for example, on the website of the chamber of psychotherapists of the respective federal state. Page. As an example for NRW: https://www.ptk-nrw.de/patientenschaft/psychotherapeutensuche. A total of three to five psychotherapists should be contacted by telephone or e-mail. A record of this search and contact should be kept, including the following information: Name of the psychotherapist, date and time of contact and the waiting time for a treatment place.

In principle, waiting periods of more than three months are considered unreasonable.

4. certificate of a licensed psychotherapist:in private practice.

The final certificate should be obtained from a licensed psychotherapist in private practice stating that treatment can be provided in the short term (less than three months waiting time). The certificate should indicate when treatment can be started and whether there is expertise in a "guideline procedure".

Graduation:

All documents are then sent together to the respective statutory health insurance company. To ensure that the documents arrive, we recommend sending them by registered mail.

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Excursus: guideline procedure

Guideline procedures are all psychotherapeutic directions that are scientifically recognized and covered by statutory health insurance.

These currently include:

● behavioral therapy,

● Depth psychology-based psychotherapy,

● Analytic psychotherapy,

● Systemic therapy for adults and

● Neuropsychological therapy for brain injuries.

What if the insurance company refuses?

If the health insurance company rejects the application without being able to offer the insured an alternative with a psychotherapist with a registered office, a complaint may be filed. The letter could look like this:

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Address of the insured person

Address of the health insurance company

Place, date

Insured number:

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Objection to their letter of ...

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Dear Sir or Madam,

I hereby file an objection to your letter of [insert date], in which you refuse to cover the costs incurred by me as a result of outpatient psychotherapy with Ms/Mr .... My application was accompanied by the necessary documents showing that the eligibility criteria were met. I therefore ask you once again to approve my application. If you do not approve my application, I will take legal action to enforce my claim and inform the supervisory authority and the Federal Government Commissioner for Patients.

With kind regards

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Our conclusion

It is not impossible to start psychotherapy with a private psychotherapist as an insured patient. For the application to the respective health insurance company, a total of four documents must be submitted: a formal cover letter; a certificate that the psychotherapeutic treatment is necessary and cannot be postponed; a record of the unsuccessful search for a psychotherapist licensed by the health insurance company; a certificate from a licensed psychotherapist in a private practice that the treatment can be taken over at short notice. Each of these aspects has been addressed in detail in this article.

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