What a foreigner should know about hospital and doctor’s bills in Germany

Treatment in hospitals and private practices of physicians is never free. Someone will always have to pay – and as foreigners are usually not covered by social security health insurance (which is compulsory for the majority of German citizens) this will usually be the patient. (If he has private insurance coverage, he can claim reimbursement afterwards.)

For outpatient treatment in private practice, there is a special government-regulated price list called GOÄ –Gebührenordnung für Ärzte. Here, prices for most of the activities and procedures that can happen during diagnostics and treatment, are fixed. Rather, to be more exact, a baseline price is fixed, for example for a normal consultation (also by phone), the price is 4.66 Euro. This basic price can, legally, however be multiplied by a factor of up to 3.5, if the activity was more complicated than usual, or if the doctor has agreed beforehand with the patient, that a certain multiplication factor will be applicable. So, for every visit to the physician, there should be a detailed bill which shows all the activities which where done – sometimes it is worth checking whether you can remember that all those procedures shown on that list really took place. Increasingly often, the insurance companies also check the bills and sometimes dispute critical items.

The same procedure will also be applied when the medical activity took place in a hospital on inpatient basis, if the physician has concluded a treatment contract with the patient to this effect. Such contracts are possible

• Firstly, if the physician is employed by the hospital, and the hospital has granted him the right to treat and invoice private patients – a privilege which is usually given to senior consultants or department chairmen only (for these, it is simply part of the salary deal).
• Secondly, the “Belegärzte”, physicians in private practice who have a contract with a hospital that they may treat inpatients there, will write a separate bill for their efforts. In both cases, these bills will come on top of the hospital bill.
• And if more than one physician was involved in the treatment process (e.g. cardiologist, surgeon, radiologist), each of these will present his separate bill for his activities.

Here also, the GOÄ is applicable; here also, the multiplication factors can be effective. One important aspect is: The patient is entitled to personal treatment by the physician himself, delegation to subordinate physicians is legally correct only under very restricted circumstances.

The hospital system for calculating the invoice, is another, and rather complicated process: First, based on the prevailing diagnoses and the procedures that where done, a DRG will be defined. The DRGs (Diagnosis Related Groups) are published by a governmental agency every year, the list comprises more than 900 different case rates (Fallpauschalen). For example, the DRG I78Z would be coded for the treatment of simple injuries of the shoulder, arm or leg without any complications; I44B would describe the implantation of a knee prosthesis without complications. Each of these DRGs is associated with an exact case value (for I78Z it would be a value of 0.411, for I44B the value is 2.600 in the 2007 catalogue). This DRG-value is then multiplied by the base rate of the individual hospital for the current year, which is the result of yearly negotiations of the hospital with the health insurance companies. Most base rates will be in the range of 2600.- to 2900.-Euro. So, for the activity described by I44B, the hospital bill would be 7280.- Euro if its current base rate is 2800.-Euro. All hospitals are obliged to inform patients about this system and the currently applicable base rate prior to concluding the treatment contract. There can be other, additional rates for special activities or very expensive materials, but usually these DRG prices also include the costs of implant materials, expensive pharmaceuticals etc.

The important point is now, that the DRG bill also includes the costs of medical staff, i.e. the physicians. And for social security patients, this price will be the complete cost of treatment. However, if a patient has decided to opt for private medical treatment by the senior consultant or chairman of the department, this personal treatment bill (as described above) will come on top of the DRG bill, and the patient (or his insurance company if he has coverage for that) will be responsible for both bills. The basis for such dual billing must be a dual treatment contract, which means: If, and only if, the patient has signed the additional contract for the individual medical treatment, the doctor will be entitled to the payment of his separate bill. And the interesting part: There is no obligation at all, for any patient whatsoever, to contract for this additional, optional private treatment! It is your right as a foreigner with or without insurance coverage to decline this option and go for standard medical treatment. The medical standard of your treatment will not be really different, as the doctors who will treat you are under the supervision of the same chairman who offered personal treatment. All you have to do is decline the additional contract when signing the hospital admission contract papers, and the hospital staff is not allowed to pressurize you to sign the private treatment contract as well.

And one more point: While it is true, that the DRG System is mandatory for social security patients, that does not give the hospitals complete freedom to leave this system for foreign or other private patients. There is also a rule which prohibits that hospitals make different prices for different groups of patients. So only private clinics which have no social security contract, may devise their own pricing system.

The same is incidentally true for the other optional features, like single room privacy or accommodation in a 2-patient room. Here also, the patient is free to decide whether he wants to sign for the additional options, no coercion is permitted and only the prices which are published by the hospital for all patients may be applied.

All this tells you: While there is a lot of regulation about what is permitted in terms of doctor’s or hospital billing, there is also a big range for optional agreements. And it is up to the patient, which options he contracts, sometimes substantially increasing the costs of treatment.

Also: The assistance by a patient referral organisation like German Hospital Service Ltd, can be very valuable: During the admission process and after the treatment, when someone with the relevant know-how can check the bills to make sure that there are no mistakes.