Public/ Statutory Insurance: Reimbursement Procedure

No automatic cost coverage:

I have a private practice, which means I am not licensed within the public/ statutory health insurance system.
Therefore, I cannot guarantee that your public/ statutory health insurance will cover the treatment costs from the beginning.

 

Application for reimbursement (Kostenerstattungsverfahren)

You may, however, apply for reimbursement with your health insurance provider (according to § 13 (3) SGB V) if you are unable to find a licensed psychotherapist who can offer you a therapy place within a reasonable time frame.
Unfortunately, some insurance providers categorically reject this procedure despite your legal entitlement; in such cases, I am unable to offer treatment. Most insurance providers do reimburse the costs, making this still a common and promising way to begin psychotherapy. Studies and clinical experience indicate that more than 90% of applications are approved. With my years of experience in the reimbursement procedure, I can advise you during our sessions and provide all required documents. I also cooperate with the organization Tepavi, which offers fee-based expert support for the application process.

 

Procedure:

1. We first schedule an initial consultation. During this meeting, I explain how to obtain the documents needed for the reimbursement process. If we decide to work together, I will send you the documents you need from me.

2. We then apply for the so-called probative sessions (usually 4 sessions plus one session for the biographical interview). These sessions are almost always covered by the health insurance provider. If, after these probative sessions, we decide to proceed with therapy, a further formal application is required (with no additional effort on your part).

3. Next, we would apply for ongoing therapy (24 or 60 sessions). For this, health insurance providers usually require me to write an evaluation for an external expert witness ("Bericht an die Gutachter"). I will prepare this anonymized report, and a reviewer from the Medical Service of the Health Insurance (MDK) will decide whether the therapy is approved or denied.

4. In more than 90% of cases, therapy is approved, though no guarantee or prediction can be given. Once approval and cost coverage are granted, we can begin the authorized sessions, and the costs will be reimbursed.

 

Where is the catch?

• Submitting the application involves several steps. You will need to:

  • Contact the patient service hotline (116117), which is responsible for helping you find licensed psychotherapists. 

  • Schedule a consultation ("Sprechstunde") with a psychotherapist who has a cooperation with the public insurance system. This therapist has to give you the form PTV 11, confirming that you require psychotherapy urgently and should begin treatment soon.

  • Document the psychotherapists who were unable to offer you a treatment place.

  • See a medical doctor who can issue a consiliary report and, if applicable, a certificate of urgency.

  • In rare cases, you may need to provide a written statement to your health insurer explaining why you require psychotherapy.

None of these steps should take more than a few hours. The process with the insurance provider, however, can feel lengthy and demanding at times, and you may need to advocate strongly for yourself. It is important to communicate clearly what you need and to assert your right to receive it.

• The initial consultation with me unfortunately must be paid privately, as the insurance provider only covers costs after the approval of your application - an application we can only submit after the initial consultation.
  The cost of the initial consultation (GOP 812a) is €134.06 (for 50 minutes). After our appointment, I will send you an electronic invoice (PDF), which must be paid within one week.

• Legally, no contract is ever established between me and your health insurance provider; instead, you and I are the contractual partners. This means that, unfortunately, I have no legal claim to reimbursement from the insurance provider. As a result, insurers may occasionally refuse coverage, reimburse only part of the costs, or pay with delays.

• I also have no influence on whether or to what extent your insurance provider reimburses your expenses.
  If difficulties arise, you would need to contact the insurance provider directly. In most cases, however, costs are reimbursed in full, often within just a few days.

 

What if the application is unsuccessful or problems arise?

• It is possible that your health insurance provider denies cost coverage. In this case, you may submit an informal objection.

• If necessary, you may also consult a lawyer (e.g., specializing in health law) and take legal action against the decision.

• If needed, you might also consider switching to a different health insurance provider. For some insurers, the reimbursement procedure is more promising than for others.