The medical fee schedule sets down basic fees for treatments and services billed in the private health insurance system
Health insurance is mandatory for everyone living and working in Germany. You can choose between public and private health insurance, but you must take out a suitable and adequate insurance policy.
If you opt for public (statutory) health insurance, also known by its German abbreviation GKV, the treatments and services covered by your policy will largely be determined by Book V of the German Social Code (SGB V). In the GKV system, bills are settled between the doctor and the insurance provider – so the GOÄ does not directly affect GKV policyholders.
If you choose private health insurance, also known by its German abbreviation PKV, the scope of coverage will be contractually agreed in your policy. Privately insured people pay medical bills themselves before applying for reimbursement from their insurance provider.
These bills are calculated on the basis of the official medical fee schedule, which sets down basic fees for specific services. Doctors can multiply this fee by an incremental factor of up to 3.5 depending on the complexity of the treatment, the time required, and the circumstances in which the treatment is administered. The average multiplier applied is 2.3 times the basic fee in the GOÄ. Doctors must agree this rate with patients in advance, which allows the patient to check whether their private insurance provider will cover the cost of treatment.
At ottonova, we cover up to 3.5 times and in the First Class tariff even 5 times the basic fee set down in the GOÄ. In our special Expat tariff we also cover up to 5 times the basic fee, which can be helpful if you need to see a leading specialist.