Private Health Insurance Claims: How to Read Your Bill

Learn how to read a GOÄ bill and your private health insurance claim statement, including factors, excess, deadlines and common reasons for reductions.

A private health insurance claim consists of two documents. The first is your doctor’s bill under the German fee schedule for doctors (GOÄ). The second is the statement from your insurer showing what is reimbursed. You pay the doctor’s bill first and submit it afterwards. The amount is determined by the points for the service, a point value of 5.82873 cents and a scaling factor. For personal medical services, the threshold value is 2.3 and the maximum rate is 3.5.

Quick answer

A private health insurance claim has two parts. The first is the doctor’s bill under the GOÄ, the second your insurer’s statement. You pay first and submit the bill, and the insurer reimburses according to your tariff. The amount follows from points, a point value of 5.82873 cents and a factor of up to 3.5.

The key points in brief

Privately insured patients receive the bill themselves and submit it to the insurer (cost reimbursement principle). There is no direct contractual relationship between doctor and insurer.
The basic rate is the number of points multiplied by 5.82873 cents. The scaling factor multiplies this amount.
Threshold value and maximum rate: 2.3 and 3.5 for personal medical services, 1.8 and 2.5 for medical-technical services, 1.15 and 1.3 for laboratory services.
Above the threshold value, the doctor must individually justify each service on the bill. Above the maximum rate, a written fee agreement is needed before treatment.
How much you get back depends on your tariff, namely the reimbursement rate, the excess and the maximum factor the tariff covers.
Bills can be submitted within three years from the end of the billing year.

What does a private health insurance claim involve?

Private billing means that the practice charges its services under the GOÄ and issues the bill to you as the patient. The health insurer and the association of statutory physicians (Kassenärztliche Vereinigung) are not involved in this process. Dentists bill under their own fee schedule, the GOZ. The principle is similar. You can find details on dental services in private health insurance (in German) in a separate article.

Private billing is not limited to privately insured patients. Statutory insured patients also receive a private bill if they want services outside the statutory catalogue and pay for them themselves. The difference lies afterwards. Privately insured patients submit the bill to their insurer, while statutory patients usually pay such costs themselves.

How does billing work for private and statutory patients?

In statutory insurance, the practice bills the health insurer directly and you do not see the bill. In private health insurance it is the other way round. You receive the bill, pay it and get the money back from your insurer.

Feature	Statutory (benefit in kind)	Private (cost reimbursement)
Who receives the bill?	The health insurer, not you	You, as the patient
Who pays first?	The health insurer, you only show your insurance card	You, then the insurer reimburses you
Basis for prices	Fees paid to statutory physicians	GOÄ (doctors), GOZ (dentists)
What is paid?	The health insurer’s benefit catalogue	What your tariff provides
Hospital	Billing between hospital and health insurer	Direct billing between hospital and insurer is the rule

The advantage of this system is transparency. You see every billed service with its factor and amount and can check yourself whether the bill matches your visit. The downside is that you pre-finance the costs until reimbursement.

Statutory insured patients can also choose cost reimbursement under § 13 (2) SGB V. They must inform the health insurer in advance and are bound to it for at least one calendar quarter. Reimbursement is capped at the amount of the benefit in kind, minus an administrative cost deduction of up to 5 percent.

What does a GOÄ bill look like?

Each service has a number of points under the GOÄ. Multiplied by the point value of 5.82873 cents, this gives the basic rate. This amount is multiplied by a scaling factor, and the result appears on the bill as the amount. Within the fee range, the doctor sets the amount at their reasonable discretion, for example according to difficulty and time required. The Federal Agency for Civic Education also explains the basics of private medical fees.

Each line on the bill usually shows the date, the fee item number, a short description of the service, the factor and the amount. The total at the bottom is the amount you pay and submit.

What do threshold value and maximum rate mean on the bill?

The threshold value is the factor up to which a doctor may bill without special justification. The maximum rate is the upper limit of the fee range. Both depend on the type of service.

Type of service	Threshold value	Maximum rate
Personal medical services	2.3-fold	3.5-fold
Medical-technical services	1.8-fold	2.5-fold
Laboratory services	1.15-fold	1.3-fold

If the factor is above the threshold value, the doctor must justify the service in writing on the bill, based on the patient, the illness or the circumstances. Generic formulas are not enough. If the doctor wants to bill above the maximum rate, they need a written fee agreement in advance under § 2 GOÄ. Such an agreement is not permitted in emergencies or acute pain treatment.

How do you calculate a GOÄ item?

Example with a fictitious service. A service has 100 points. These are not real values of a fee item number. They are for illustration only.

Factor	Calculation	Amount
1.0 (basic rate)	100 × 5.82873 cents	€5.83
2.3 (threshold value)	€5.82873 × 2.3	€13.41
3.5 (maximum rate)	€5.82873 × 3.5	€20.40

If the practice bills this service with factor 3.5 and your tariff reimburses only up to the 2.3-fold rate, €6.99 remain as your own share. For a single item that seems small. With several items per visit and several visits per year, it adds up.

What does your insurer’s reimbursement statement contain?

The reimbursement statement, often called the claim statement, comes from the insurer and summarises what it pays for the bills submitted. Its layout differs between insurers. Typical information includes the following items.

the amount billed for each bill submitted
the reimbursable amount under the terms of your tariff
the reimbursement rate as a percentage
any deduction for the excess
the payout amount and any reductions, with a short reason

First check whether the total of the bills matches what you submitted. Then compare each reduction with the reason the insurer gives. If a reason is missing, you can ask for it.

Why does private health insurance not always reimburse the full bill?

Reimbursement depends on your tariff. The tariff specifies which services are covered and to what extent. Typical reasons for reductions are a factor above what the tariff reimburses, a reimbursement rate below 100 percent, an outstanding excess or a service the tariff does not provide for. For an overview of what private health insurance covers for students (in German), see our dedicated article.

This also applies to individual types of care. Whether and to what extent costs for travel vaccinations (in German), preventive care during your studies (in German) or ambulance costs (in German) are covered is set out in the conditions of your tariff.

How does an excess affect billing?

The excess is the amount you bear yourself each year before the insurer pays. The tariff sets the amount.

Example with assumed values: Lea, 24, has a tariff with a €500 excess per year and 100 percent reimbursement above it. Her first bill of the year is €320. The insurer pays nothing, and the bill is credited against the excess. Her second bill is €400. Of the excess, €180 is still outstanding (€500 minus €320), which the insurer deducts, and it reimburses €220.

An excess lowers the premium, but it requires you to pre-finance larger bills and to have reserves for the year. The reimbursement statement shows you how much of the excess has already been used.

Does it pay off not to submit bills?

That depends on the tariff. Some insurers pay a premium refund if no bills were submitted for a year and they have surpluses. According to one advice source, such a performance-based refund can amount to up to around 50 percent of an annual premium. This is a guide value and not a promise. Before you decide not to claim, weigh this up. How high is the bill, and how high is the possible refund?

How do you submit bills and how long do you have?

You can submit bills within three years from the end of the year in which they were issued. Example. A bill from March 2026 can be submitted until 31.12.2029. Still, submit promptly so that you keep track of the excess and outstanding amounts.

Your insurer decides how submission works in detail, for example via an app, a portal or by post. For inpatient treatment, the hospital usually bills the insurer directly.

What do you do if the bill or the reimbursement is wrong?

Proceed in this order:

Check whether the services billed match your visit.
Look at the factors. If one is above the threshold value, an individual justification must appear on the bill.
Ask the practice for a correction or justification if something is missing or unclear.
Ask the insurer in writing how a reduction came about, and check the terms of your tariff at the same time.

If you signed a fee agreement before treatment, the factor agreed there applies. Without an agreement, the maximum rate must not be exceeded.

What changes with the GOÄ reform?

The GOÄ is based on a version from 1982. The Federal Chamber of Physicians and the PKV association have submitted an updated version of their joint draft to the Federal Ministry of Health (press release of the Federal Chamber of Physicians dated 31.07.2026). It envisages fixed euro amounts instead of scaling factors.

Important. This is a plan. The reform only becomes legally binding through a regulation of the federal government. Until then, the existing GOÄ applies. No date has been set. The associations name 1 January 2028 as achievable, but that is not a commitment.

Frequently asked questions

What is the difference between a doctor’s bill and the claim statement?

The doctor’s bill is issued by the practice under the GOÄ. It shows what you pay for the treatment. The claim statement, also called the reimbursement statement, comes from the insurer. It shows which part of the bills submitted it reimburses under your tariff and, where applicable, why it reduces an amount.

Do I have to pay the doctor’s bill myself as a privately insured patient?

As a rule, yes. Privately insured patients first pay the bill themselves and submit it to the insurer. There is no direct contractual relationship between doctor and insurer. For inpatient treatment, however, direct billing between hospital and insurer is the rule.

Can a doctor bill more than 2.3 times the rate?

For personal medical services, yes, up to 3.5 times the rate. The doctor must then justify the service on the bill, based on the patient, the illness or the circumstances. Billing above the maximum rate requires a written fee agreement in advance, and such an agreement is not permitted in emergencies or acute pain treatment.

How long can I submit bills to my insurer?

You have three years from the end of the year in which the bill was issued. A bill from March 2026 can therefore be submitted until 31.12.2029. Your insurer determines how you submit it.

So what should you do now?

Put each doctor’s bill next to the table of threshold values and check the factors.
Submit the bill to your insurer promptly.
Compare the reimbursement statement with the bill and ask about any reductions.
Check your tariff terms for the maximum factor, reimbursement rate and excess that your tariff provides.

If you are still considering whether private health insurance is right for you, the process is explained in how to switch to private health insurance as a student (in German). Note that the exemption from compulsory insurance generally applies for the entire course of study and cannot be revoked. A return to statutory insurance is usually only possible after your studies, and premiums may rise over time. If you want to talk through your situation, you will find the way to a consultation on the Academycon homepage.

You can find experiences with us on ProvenExpert, Trustlocal and Trustindex. Academycon was also mentioned in a report by VersicherungsJournal. An overview of all mentions is on the press page (in German).

Sources

Last updated: October 2026. This guide is general information, not individual advice. The German version is authoritative.