Reimbursement, Not Direct Billing
Private patients in Germany work on the Kostenerstattung (reimbursement) principle: the doctor bills you, you submit the invoice to your insurer, and the insurer sends back a Leistungsabrechnung — a statement showing what it paid and, crucially, what it did not. Learning to read it is the difference between accepting a silent short payment and reclaiming money that is rightfully covered.
The Lines That Matter
Most statements list each item from the doctor’s invoice with several columns. The key ones:
| Field | What it tells you |
|---|---|
| Rechnungsbetrag | The amount the doctor billed for that item |
| Erstattungsfähig / anerkannt | The amount your tariff recognises as eligible |
| Erstattungsbetrag | What the insurer actually pays you |
| Selbstbehalt / Eigenanteil | Deductible or co-payment applied before payment |
| Kürzung / Begründung (code) | Any reduction, with a reason code explained in the footnotes |
Why the Insurer Paid Less Than the Bill
A gap between what you were billed and what you were paid usually has one of a handful of causes, and the statement names it:
- Deductible: your annual Selbstbehalt is being consumed — this is not a refusal, just your agreed excess
- GOÄ rate factor: the doctor applied a high Steigerungssatz (multiplier) and your tariff only covers up to a certain factor without extra justification
- Tariff caps: some items (glasses, dental, alternative medicine) have annual or percentage limits
- Missing detail: an unclear diagnosis or missing document — often fixable by resubmitting
Read the footnotes. The reason codes at the bottom of the statement are where the real information lives. A code such as “treatment not medically necessary” or “exceeds customary rate” tells you whether to accept the cut or contest it.
How to Challenge a Short Payment
If a reduction looks wrong, you have a straightforward route: write to the insurer citing the invoice item and the tariff clause you believe covers it, and ask for a written reason for the reduction. For rate-factor disputes, your doctor can supply a short medical justification (Begründung) for the higher multiplier — reattach it and resubmit. Keep every statement; deductibles and annual limits are tracked across the year, and you will want your own running total to check the insurer’s.
The Bottom Line
The Leistungsabrechnung is not just a receipt — it is the insurer explaining its decision in a code you can learn. Match each reduced line to its reason, separate genuine deductibles from contestable cuts, and you turn a confusing document into a tool for getting every euro your tariff owes you.
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