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Cost reimbursement instead of benefits in kind in statutory health insurance

Normally, doctors in statutory health insurance bill the fund directly (benefits in kind). Insured persons can, however, choose cost reimbursement instead: they pay the invoice themselves first and have it reimbursed. This has advantages and disadvantages.

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Your chances of getting your money back

Statutory insured persons can choose cost reimbursement instead of benefits in kind (§ 13 SGB V). They then deal with the doctor like private patients and have the fund reimburse the costs.
At most, what the fund would have paid under benefits in kind is reimbursed, minus administrative costs and deductions. A considerable co-payment can remain. The choice also usually binds you for a calendar quarter.

What you should do now

  1. 1

    1. Understand the consequences

    Be aware of the possible co-payments and the commitment period.

  2. 2

    2. Declare your choice

    Notify the fund of your choice of cost reimbursement in writing.

  3. 3

    3. Collect invoices

    Have invoices issued according to the fee schedule and submit them.

  4. 4

    4. Check the reimbursement

    Check what is reimbursed and what co-payment remains.

How to spot the scam

  • High co-payments are underestimated.
  • The commitment to the choice for several months is overlooked.
  • Invoices are not submitted or are submitted too late.

Frequently asked questions

What does cost reimbursement in the GKV mean?

Instead of direct billing between doctor and fund (benefits in kind), you choose to pay the invoice yourself and have the fund reimburse you (§ 13 SGB V). You are treated by the doctor like a private patient.

Do I get the costs fully reimbursed?

No, usually not. At most, the amount the fund would have borne under benefits in kind is reimbursed, reduced by deductions for administration and the missing efficiency review. Private medical invoices are often higher, so a co-payment remains.

Can I switch back at any time?

The choice of cost reimbursement usually binds you for at least one calendar quarter. Only afterward can you return to benefits in kind. So think the choice through carefully and clarify the consequences with your health insurer in advance.

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General information for self-help, not legal advice (RDG). In case of a high loss or uncertainty: contact a consumer advice center or a lawyer.