Health Insurers Don’t Have to Reimburse for Invalid Medical Billing Codes
A recent ruling by the Landessozialgericht (LSG) Berlin-Brandenburg, Germany’s regional social court, clarifies that health insurance companies are not obligated to reimburse costs for privately funded medical treatments if the physician uses an invalid billing code from the Gebührenordnung für Ärzte (GOÄ), the German medical fee schedule. This decision underscores the importance of accurate billing practices in healthcare.
The Case: Immunoadsorption and Billing Errors
The case stemmed from a legally insured patient who underwent privately financed immunoadsorption – a blood purification process used to remove disease-relevant antibodies – after their health insurance initially denied coverage. The patient subsequently sought reimbursement from their health insurer for the private medical bills. However, the physician had used a GOÄ fee number that did not exist.
Court’s Reasoning: Effective Payment Obligation
The LSG Berlin-Brandenburg ruled against reimbursement, stating that a claim for cost reimbursement is only valid if the insured party had a genuine and enforceable payment obligation. For an invoice to be considered valid, it must meet the minimum requirements outlined in the GOÄ, crucially including the correct fee number. Because the submitted invoice contained a non-existent GOÄ number, it was deemed invalid and did not create a reimbursement obligation for the health insurance company. Landessozialgericht Berlin-Brandenburg
Understanding the GOÄ
The GOÄ is a central component of the private health insurance (PHI) system in Germany. It regulates the billing of medical services to privately insured patients and establishes the fee rates for those with full or supplementary insurance coverage. zeb-consulting.com Accurate application of the GOÄ is therefore essential for both healthcare providers and insurers.
Implications for Patients and Providers
This ruling highlights the importance of patients carefully reviewing their medical bills to ensure accuracy, particularly the GOÄ fee numbers listed. Healthcare providers must as well ensure they are using current and valid GOÄ codes when billing for services. Errors in billing can lead to denied claims and financial burdens for patients.
About the Landessozialgericht Berlin-Brandenburg
The Landessozialgericht Berlin-Brandenburg is a regional social court responsible for hearing appeals related to social law matters in the states of Berlin and Brandenburg. On March 3, 2026, Anja Gorgels was appointed as the Vice President of the court by President Jes Möller. Landessozialgericht Berlin-Brandenburg
Judgment Reference: L 4 KR 289/21