News

Verdict: Even without referral to the hospital


BSG: Clinical remuneration also for self-instructors

Statutory health insurers can also go to the hospital as "self-referrers" without a referral. A referral from a contract doctor is not required for the clinic's claim to reimbursement, ruled on Tuesday, June 19, 2018, the Federal Social Court (BSG) in Kassel (ref .: B 1 KR 26/17 R). Contrary provisions in the contracts concluded between health insurers and hospitals are then ineffective.

In doing so, the BSG awarded a psychiatric hospital near Hanover the remuneration of just under 5,600 euros. In 2011, he had treated a patient on a day-patient basis for several weeks. The clinic is approved for health insurance patients. The medical service of the health insurance companies (MDK) later confirmed that the treatment was necessary, economical and also successful here.

The AOK Lower Saxony still does not want to pay the bill. The treatment was inadmissible because the patient did not have a referral from a contract doctor. According to the state security contract concluded between crass and hospital associations, this was a prerequisite for the "necessity" of treatment. Corresponding regulations also exist in the other countries.

As the BSG decided, they violate the Social Code and are therefore ineffective. The right to reimbursement resulted directly "by law" if the hospital was approved and the treatment was "necessary and economical".

In contrast, a transfer is not a prerequisite. The Kassel judges emphasized that this would also expose the hospitals to “unreasonable liability risks”. "You must not simply send insured persons who present themselves with acute symptoms without a doctor's briefing without an examination."

However, patients cannot expect to find open hospital doors for every ailment. Because regardless of the Kassel judgment, hospitals can only continue to treat if this is necessary. Accordingly, they bear the risk for cases in which hospital treatment proves to be unnecessary because equivalent treatment would also have been possible on an outpatient basis with a resident doctor. mwo

Author and source information


Video: NHS e-Referral Service (August 2020).