Kostenerstattungsprinzip

The core difference between GKV and PKV billing

Germany's statutory system runs on the Sachleistungsprinzip: you hand over your GKV card, the doctor treats you, and the Krankenkasse (statutory health-insurance fund) pays the doctor directly. You see no bill, no amounts, no codes.

The PKV is different. It runs on the Kostenerstattungsprinzip, the reimbursement principle, under § 192 VVG. The mechanic:

1. You are the contractual partner of the doctor, therapist, or hospital, not your insurer 2. They bill you directly under the GOÄ (physicians) or GOZ (dentists) 3. You submit the invoice to your PKV, which reimburses you within the tariff's scope 4. In theory you pay the provider first. In practice, reimbursement almost always arrives before the invoice's payment deadline

For expats used to the GKV card-swipe model, this is the most jarring cultural shift in the PKV, it takes a couple of billing cycles to feel normal.

What has to be on the invoice

German physicians' invoices follow § 12 GOÄ. A compliant invoice contains:

• Date of each service provided

• GOÄ code and description for every item

• The applied factor (Steigerungssatz)

• Written justification for any factor above 2.3× (or 1.8× for technical services)

The ICD-10 diagnosis is not strictly required but is usually included, most PKV insurers expect it for plausibility.

How to submit

The workflow most PKV insurers prefer:

• App or online portal, photograph or PDF-upload the invoice

• Email, second-best, accepted by most

• Post, tolerated but increasingly rare

Typical reimbursement timeline: 1-3 weeks between submission and payment. Some insurers commit to faster turnaround in their premium tariffs.

The most common mistake: missing referrals

Newcomers to the PKV regularly run into the same issue: they visit a specialist or start physiotherapy without a referral (Überweisung) from their GP, and then find the bill is either reduced or rejected entirely.

Most PKV tariffs require:

• A referral (Überweisung) before seeing a specialist, tariff-dependent

• A written prescription (Privatrezept) before starting physiotherapy, speech therapy, or occupational therapy

• A cost estimate (Kostenvoranschlag) for larger medical aids (hearing aids, prostheses, orthopedic equipment)

• A Heil- und Kostenplan (HKP) for extensive dental work, even where not legally required, always submit it upfront

The rules are in the AVB (Allgemeine Versicherungsbedingungen, the general policy terms). Read them during onboarding, the learning curve is short but the first mistake is expensive.

Hospital stays: the Direktabrechnung exception

For inpatient hospital stays, PKV members rarely go through the reimbursement loop. Instead:

• Before admission, you sign a Wahlleistungsvereinbarung (chief physician, single or double room) and present the insurer's Krankenhauskostenübernahmeerklärung or digital equivalent (Klinik-Card, Card4Health)

• The hospital bills the PKV directly for the general costs (DRG)

• The chief physician's fee is a separate bill, goes to you, and you submit it like an outpatient invoice

One exception: if the insurer suspects a breach of pre-contractual disclosure (§ 19 VVG), for example, a chronic condition that was not declared on the application, the direct payment to the hospital can be held back pending review. Rare, but real.

Why it exists

The Kostenerstattungsprinzip is not an accounting quirk. It is the reason the PKV can offer treatment flexibility the GKV cannot, you can see any private-practice specialist without a primary-care gatekeeper, choose premium medications, opt for premium dental work, because the financial relationship sits directly between patient and provider. The insurer steps in only when the claim is submitted.

The trade-off is paperwork. Every member learns to keep a simple filing system: invoices received, invoices submitted, reimbursements received. A running spreadsheet or the insurer's app solves it in minutes per month.