Cost reimbursement private insurance works like this: you pay the doctor’s bill first and submit it to your insurer, which reimburses you according to your tariff. You have three years from the end of the year in which the bill was issued to submit it. For inpatient treatment, the hospital usually settles directly with the insurer.
The most important points at a glance
- Privately insured patients pay outpatient bills first (advance payment) and receive the money back from the insurer.
- How much is reimbursed is determined by the reimbursement rate, the deductible and the terms of your tariff.
- Doctors bill under the scale of fees for physicians (Gebührenordnung für Ärzte, GOÄ). Up to the threshold value (2.3 times for personal medical services), no justification is required.
- You can submit bills until the end of the third year after the billing year.
- In hospitals, direct billing between the hospital and the insurer is the rule.
What is the principle of cost reimbursement in private health insurance?
The principle of cost reimbursement means: you are the contracting party of the doctor and owe them the fee. There is no direct contractual relationship between the doctor and the insurer. The insurer reimburses you for the costs, as far as your tariff covers them. How high the reimbursement is depends on your tariff.
In statutory insurance it works differently. There, practices bill directly with the health insurer via the insurance card, and you receive the treatment as a benefit in kind. Which benefits the various tariffs cover is shown in our overview of private health insurance benefits (in German).
Do I have to pay in advance as a private patient?
For outpatient treatment, such as at the doctor, dentist or physiotherapist, usually yes. You receive a bill, pay it and then submit it to your insurer. Plan a small buffer in your account, especially for larger treatments such as dentures.
For inpatient treatment it is common for the hospital to bill directly with the insurer. With hospitals that do not have a statutory approval, it is worth asking your insurer beforehand how billing works, as the article What is a private clinic? (in German) describes.
How does cost reimbursement private insurance work step by step?
- Pay the bill and check whether the services and details are correct.
- Submit the bill to your insurer, depending on the provider by post, app or customer portal.
- The insurer checks whether the service is covered by your tariff and whether the bill is correct under the fee schedule.
- You receive a reimbursement statement and the transfer of the reimbursable amount.
- Keep the bill and the statement in case there are queries or deductions.
What is the reimbursement rate, and how does the deductible work?
The reimbursement rate states what percentage of the reimbursable costs the insurer covers. Depending on the tariff and the area, it is 100 percent or less, often with maximum amounts. For aids, rates of 75, 90 or 100 percent are common, for example. The deductible is the amount per year that you bear yourself before the insurer pays. Rates for doctors, medication, aids, dental care and alternative methods differ depending on the tariff. Our article on naturopathic practitioners and private insurance (in German) gives an orientation on alternative practitioners and natural remedies.
Example with freely chosen assumptions: your tariff has a deductible of 300 € per year and a reimbursement rate of 80 percent. The deductible is deducted first. In the year you submit two doctor’s bills.
| Item | Amount |
|---|---|
| Bill 1 (specialist) | 200 € |
| Bill 2 (general practitioner and laboratory) | 400 € |
| Sum of the bills | 600 € |
| Less deductible | 300 € |
| Reimbursable remainder | 300 € |
| Reimbursement at 80 percent | 240 € |
| Your own share (600 € minus 240 €) | 360 € |
Whether the insurer deducts the deductible first or applies the rate first is set out in the tariff terms and can change the result.
A further component is the contribution refund: many tariffs pay back part of the annual contributions if you submit no bills for a year. For small amounts, therefore, check whether submitting is worthwhile. The refund reduces your deductible special expenses in the year it is paid out.
How high may the doctor charge?
Medical services are billed under the scale of fees for physicians (GOÄ). The basic rate results from the number of points multiplied by the point value. The doctor may increase this by a factor.
| Type of service | Threshold value | Maximum rate |
|---|---|---|
| Personal medical services | 2.3 times | 3.5 times |
| Medical-technical services | 1.8 times | 2.5 times |
| Laboratory services | 1.15 times | 1.3 times |
Up to the threshold value, the doctor needs no justification. Above it, the bill must justify each service in relation to the patient, the illness or the circumstances, and generic justifications are not enough. Above the maximum rate, a written fee agreement under § 2 GOÄ is required before treatment. An understandable explanation is offered by the Federal Agency for Civic Education (Bundeszentrale für politische Bildung).
A reform of the GOÄ is planned but not yet decided. The Federal Chamber of Physicians and the PKV Association have sent the Federal Ministry of Health a joint draft. The reform only becomes legally binding through a regulation of the federal government, until then the existing GOÄ applies.
How long does reimbursement take?
There is no uniform processing time. It depends on the insurer and on whether the bill is complete and comprehensible. Queries prolong processing. You can avoid missing details by checking the bill before you submit it. If the insurer does not respond for a long time, a reminder quoting the date of submission helps.
Until when can you submit bills?
You can submit bills within three years from the end of the year in which they were issued. The deadlines follow the limitation rule.
| Bill issued | Can be submitted until |
|---|---|
| March 2026 | 31 December 2029 |
| December 2026 | 31 December 2029 |
| February 2027 | 31 December 2030 |
What do you do if there is a deduction or rejection?
First read the reason given in the reimbursement statement and compare it with the tariff terms. Possible reasons are services that are not insured, maximum amounts, the deductible, or a bill above the threshold value without justification. In the last case you can ask the doctor for a supplementary justification.
If the deduction stands, ask the insurer in writing for a reason and, if necessary, lodge an objection. The consumer advice centre can also help with disputes.
Frequently asked questions
What is the difference between cost reimbursement and benefits in kind?
With benefits in kind in statutory insurance, you receive the treatment and the practice bills the health insurer. With cost reimbursement you pay yourself and get the money back. Statutory insured people can choose cost reimbursement, must inform their insurer beforehand 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 at most 5 percent.
What happens if the doctor bills above the maximum rate?
This is only permissible with a written fee agreement under § 2 GOÄ concluded before treatment. In emergencies and acute pain treatment it is excluded. Whether your insurer reimburses the higher amount is governed by your tariff. Have the agreement explained to you before you sign it.
Can I collect bills and submit them together?
That is possible within the three-year deadline. However, note the deductible and the contribution refund: if you submit nothing for a year, you may be entitled to a refund, while submitted bills can reduce it. The exact rules are in your tariff.
How to proceed now
- Note the deductible, reimbursement rates and maximum amounts from your tariff terms.
- Set aside a buffer for advance payments that fits your usual doctor’s bills.
- Check every bill before submitting it for services, data and justifications above the threshold value.
- Put the deadline for submitting last year’s bills in your calendar.
- If you want to talk through your situation, you will find the way to advice on the Academycon homepage.
You can read about your experiences with us on ProvenExpert, Trustlocal and Trustindex. Academycon was mentioned, among other places, in a press release in the Süddeutsche Zeitung press portal. An overview of all mentions is on the press page.
Related articles
- The insurance overview for students (in German)
- Medication in private health insurance (in German)
- What private patients get: doctor, clinic and therapy (in German)
Last updated: October 2026. This guide is general information, not individual advice. The German version is authoritative.
