Reimbursement in the Ambulatory Sector

Reimbursement in the outpatient area on the basis of EBM or GOÄ

In the outpatient sector (outpatient in doctors’ offices or less than 24 hours in hospital), medical services are billed on the basis of the Einheitlicher Bewertungsmaßstab (EBM) or the Gebührenordnung für Ärzte (GOÄ).

The EBM regulates the billing of services provided by contract physicians to patients with statutory health insurance. The GOÄ, on the other hand, is used to calculate the costs of services provided by private physicians to private patients or self-pay patients.

Billing is not done directly with the health insurance companies, but via the Association of Statutory Health Insurance Physicians (KV).

Consultation on the market introduction of medical devices with and without reimbursement of costs

In principle, procedures are reimbursed in the EBM or GOÄ system rather than directly their product, although it is the detail that matters here. Here sananet can first analyze for life science and medical technology companies whether reimbursement is possible in principle.

Medical products that are not reimbursed here have a difficult time entering the market. This does not mean, however, that market success is not possible without reimbursement. sananet’s expertise lies in finding long-term ways to achieve reimbursement and, in the short term, to enable market entry and initial sales through benefit arguments or alternative paths.

Consulting alternative ways of reimbursement

The adjustment period of the EBM catalog for a specific digit is about 5 years, but varies depending on the evidence. Thus, obtaining a new billing digit would be more of a long-term plan. However, if the medical procedure and its medical product are not initially reimbursed, then there are alternative ways that can still make a successful sale possible.

The sananet consulting firm specializes in reimbursement and will guide you through these alternative paths to successfully market your medical product.

Some examples of alternative routes to reimbursement for medical products are:

– Selective contracts can supplement collectively bargained care. They offer the opportunity to test new optimized concepts of patient care.
– Some procedures that are neither listed in the EBM nor covered by individual contracts between health care providers and payers can be used by patients, but must be paid for out of their own pockets. These services are referred to as “individual health care management” (IGeL).
– In addition, there is the so-called “individual case request”, where patients can apply for exceptional cost coverage by the health insurance company in their individual case.

Advice on DiGA

A relatively new avenue for software and digital medical devices may be DiGA, the digital health application.
With the fast-track process for adding DiGA to the BfArM directory, there is an unusually fast path to reimbursement. Within three months, the BfArM reviews the manufacturer’s claims on safety, performance, data protection, medical quality and interoperability of DiGA, among other things, as well as scientific evidence of its positive care effect.
Contact sananet to find out whether your medical software or digital medical device is eligible for DiGA and what the best way to apply is.