Verdict Even without referral to the hospital

BSG: clinic remuneration also for self-referrers

Statutory health insurance can also go to the hospital without referral as a "self-referral". For the compensation claim of the clinic, the referral by a contract doctor is not required judged on Tuesday, June 19, 2018, the Federal Social Court (BSG) in Kassel (Az .: B 1 KR 26/17 R). Contrary regulations in the contracts between cash registers and hospitals are ineffective thereafter.

In hypovolemic shock, balancing fluid loss via infusions is usually a fundamental part of treatment. (Image: bilderstoeckchen / fotolia.com)

Thus, the BSG awarded a psychiatric hospital in Hanover, the billed compensation of just under 5,600 euros. In 2011, it treated a patient for several weeks as a part-time nurse. The clinic is approved for health insurance patients. The medical service of health insurance (MDK) also later confirmed that the treatment was necessary, economical and successful here.

The AOK Niedersachsen does not want to pay the bill. The treatment was inadmissible because the patient had no referral from a contract doctor. However, according to the Land security agreement between Krassen- und Krankenhausverbände, this was a precondition for the "necessity" of the treatment. Corresponding regulations also exist in the other countries.

As the BSG decided, they violate the Social Code and are therefore ineffective. The claim for compensation was made immediately "by law" if the hospital was approved and the treatment was "necessary and economical".

In contrast, a transfer is not a requirement. This would expose the hospitals also "unreasonable liability risks", emphasized the Kassel judges. "You can not simply send insured persons without acute contractions with acute symptoms, without examination."

However, patients can not expect to find open hospital doors for every ailment. Because regardless of the Kassel judgment hospitals may continue to treat only if necessary. Accordingly, they bear the risk of cases in which hospital treatment proves unnecessary, because an equivalent treatment would have been possible on an outpatient basis with a general practitioner. mwo