Leave the hospital for express medical advice What can happen then?

LSG Hamburg: Clinic receives only a lump sum when re-admission
(Jur). If a patient has to return to the hospital a short time later after an operation because of complications that occur, the clinic can not bill the interventions individually. This also applies if the patient has prematurely left the clinic for medical advice, but the subsequent complications are not undoubtedly attributable to it, the Landessozialgericht (LSG) Hamburg ruled in a ruling published on Tuesday, 6 September 2016 (Az. : L 1 KR 116/13). Because of fundamental importance it allowed the revision to the Federal Social Court (BSG) in Kassel.

In the specific case, it was about the billing of inpatient hospital treatment of a toddler. The child admitted on 2 July 2008 was surgically removed on the back the next day. The procedure itself went well, but shortly afterwards a pressure bandage had to be applied because of heavy bleeding.

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The doctors advised the mother to leave the child in the clinic until July 7, 2008. But contrary to the medical advice, the mother took the child home two days earlier. In the dismissal note, the doctors noted as risks: "wound infection, secondary bleeding, death by fatality".

On July 16, the child had to be hospitalized again at the clinic, as the wound reopened and had to be surgically treated.

For the first treatment, the hospital demanded from the health insurance 2,458 euros, for the second stay, she charged another 1,759 euros.

The health insurance paid first, but then demanded 1,653 euros back. The clinic received a case lump sum for the treatment of the child, which includes the treatment of later complications. The two hospital stays should therefore not be billed separately.

The complications arose only because the mother took her child two days earlier against the medical advice, the clinic then argued. The mother had also missed the appointment for re-presentation on July 7, 2008.

In its judgment of May 26, 2016, the LSG made it clear that a hospital is only entitled to receive a lump-sum flat fee when it comes to re-hospitalization due to complications that occur. The prerequisite for this is that the complication still occurs within a defined upper limit for each illness. In the specific case, this was 15 days. Within this time, the complications had occurred, so that the clinic could claim only a uniform remuneration.

This is different, however, if the complications arose because of the unreasonable behavior of the insured or a third party. Here, however, there are doubts that the premature discharge caused by the mother is responsible for the second hospital stay, so the LSG. Also, the lack of documentation on the admission and the pediatrician for the period between discharge and resumption was no clarity. According to the case law of the SPA, however, the risk of non-evidence of the cause of the wound healing disorder leading to readmission must in principle be borne by the plaintiff's hospital. fle / mwo
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