Reimbursement of Expenses Psychotherapy: The Reimbursement of ExpensesCheckout process when no checkout lane is available

The consultation is over, you have the written referral for psychotherapy right in front of you, and yet there is no therapy slot available.

The cost reimbursement procedure is the legal fallback option in an overcrowded healthcare system. If you cannot find a therapy slot with a contracted psychotherapist, that does not mean you have run out of options. People with public health insurance Under certain conditions, they can also receive treatment from therapists who are not enrolled with health insurance providers and are reimbursed for the resulting costs by their health insurance provider. The legal basis for this is § 13(3) of Book V of the Social Code (SGB V).

The text of the law is brief. If the health insurance provider was unable to provide an urgent service in a timely manner, the costs of the service obtained by the insured person must be reimbursed, provided the service was necessary. Legal experts refer to this as System Failure. This refers to the mandate to provide care that statutory health insurance plans have but cannot fulfill in individual cases.

The entitlement remains unchanged. What has changed is how readily health insurance providers recognize it.

Three conditions must be met: psychotherapy is necessary and needed promptly, the search in the health insurance system was unsuccessful, and the selected practice meets the professional requirements.

The first requirement is met during the psychotherapy consultation. During this consultation, it is determined whether outpatient psychotherapy is indicated and how urgent it is. You fulfill the second requirement yourself by providing a record of your inquiries. For the third requirement, contact the relevant practice.

Who Is Authorized to Provide Psychotherapy

This condition is stated verbatim in the law and is often overlooked in most guidebooks: costs are reimbursable provided that the psychotherapist meets the requirements of the § 95c of Book V of the Social Code (SGB V) fulfilled. This means a medical license and specialty certification obtained through a process recognized by the Joint Federal Committee. The following are recognized pursuant to Section 15 of the Psychotherapy Guidelines psychoanalytically based approaches—that is, depth psychology-based and analytical psychotherapy—as well as behavioral therapy and systemic therapy.

The PTV 11 is an important document, but it is not yet a complete application for reimbursement. It documents the preliminary findings, the recommended treatment, and whether the treatment can be provided at the issuing practice.

The following documents are required for the reimbursement request: in particular, the search log and the mediation attempt via the 116117 and the records from the private practice.

No law specifies a fixed amount. That is the honest answer to the question most frequently asked during the reimbursement process. What you need to prove is something else: that you were unable to receive psychotherapy covered by your health insurance plan.

kassenwatch.de, operated by the DGVT professional association, now advises people with public health insurance to make about ten to twenty calls to licensed practices, noting each inquiry individually. There is no prescribed number; what matters is that the record clearly shows that no suitable treatment slot is available within a reasonable time and distance.

The German Association of Psychotherapists describes a system failure as follows: Insured individuals are unable, through efforts reasonably expected of them, to find an approved practice that is willing to provide treatment within a reasonable time and distance, and the health insurance provider is unable to successfully assist them in this regard. Distance is therefore a factor—it’s not just the wait time.

What Should Be Included in the Minutes

Practice name, date/time, result—for each individual call. Also note any attempts to connect through the appointment scheduling service. 116117 firmly.

A log that starts tracking from the first cancellation costs you three notes per phone call.

These calls are more than just a series of rejections. They’re an opportunity to get to know psychotherapists who will have an opening in a few months. Read on to find out how to go about this and find someone who’s a good fit for you as quickly as possible: How to Find a Psychotherapy Practice.

If you are offered a therapy slot at an approved practice, accept it. You are only entitled to reimbursement as long as no slots are available in the health insurance system. kassenwatch.de puts it this way: Such an offer should be declined only in rare and well-justified exceptional cases. If you feel absolutely uncomfortable with the psychotherapist during the initial consultation, that is, of course, a good reason not to begin therapy there.

There is no uniform application process nationwide. The following procedure has proven effective in practice and keeps the financial risk as low as possible.

The exact requirements vary from one health insurance provider to another. Therefore, if possible, ask them to provide you with a written list of the documents needed for the initial trial sessions.

The applicant is the patient. The application typically includes the PTV 11 form, the record of the search for a therapy spot, and proof of an attempt to arrange placement through the 116117 hotline. Depending on the health insurance provider, a medical certificate of urgency or, in some cases, a Consultation Report are required.

The private practice includes a cover letter. In it, the practice confirms that it can provide initial evaluation sessions on short notice and, if indicated, subsequent therapy as well. It also provides information on the therapist’s qualifications, treatment methods, and estimated costs.

You generally submit the claim for reimbursement of probatorics costs. The practice can send the complete package with your consent.

After the evaluation phase, the practice will prepare the application for short-term or long-term therapy and typically submit it to the health insurance provider. Be sure to keep a copy of all submitted documents and proof of the date they were received.

As a general rule, the health insurance provider must be given the opportunity to arrange a therapy slot on its own before the first session for which the patient is responsible for the cost. Anyone who begins treatment first and only applies for reimbursement afterward generally loses their right to reimbursement.

This also applies to trial sessions: Be sure to submit a request for coverage of these costs before your first appointment and, if possible, wait for the insurance company’s decision. Exceptions may apply, particularly in cases where treatment cannot be postponed.

As long as full coverage of the costs has not been confirmed, the practice must inform you in writing of the estimated costs before treatment begins (Section 630c(3) of the German Civil Code (BGB)). If this does not happen, caution is advised.

When the patient pays upfront

In the reimbursement process, the medical practice bills the patient for its services. Typically, you pay the bill yourself first and then submit it to your health insurance provider. You bear the risk that the insurance provider may reimburse less than the amount billed. In certain cases, instead of a retroactive reimbursement, you may request that the outstanding balance be waived.

In the reimbursement process, the patient enters into the treatment agreement with the practice, not the health insurance company. That is the difference from treatment at a participating practice, and it explains why the bill is sent to you.

If your health insurance company has denied your claim for reimbursement, you have one month to file an appeal, starting from the date of notification (§ 84 SGG). The one-month period applies if the information regarding the right to appeal is provided in the proper manner. If this information is missing or contains errors, a longer period may apply.

Request a written and reasoned decision that includes information on your right to appeal. Even a rejection communicated verbally can already constitute a decision; however, a written decision provides clear evidence of its content, the reasons for it, and the applicable deadlines.

The three most common reasons

The justifications are repetitive. They say there is an appointment scheduling service. They claim the search wasn’t sufficiently documented. They argue that the urgency wasn’t substantiated. Objective arguments can be made against each of these three points, and that is precisely what the minutes—which you’ve been keeping since the first rejection—are for.

If the appeal is unsuccessful, the next step is to file a lawsuit in social court. The proceedings are free of court costs for insured persons (§ 183 SGG). It's still not easy, but the hurdle is lower than most people think.

There is support available for this, and it's free. The Independent Patient Counseling Foundation of Germany has been providing free, nationwide advice on health and health law issues since May 2024. Through the free portal widerspruch.online An appeal can be filed automatically. And the VdK social welfare association offers its members its own legal counseling service.

An appeal is not a dispute. It is the established procedure for having a decision regarding your psychotherapy reviewed, and the office expects you to file one.

An approved reimbursement does not necessarily mean full reimbursement. Often, the health insurance provider’s decision only agrees to cover the amount that an approved practice could bill based on the Uniform Assessment Scale. However, a private practice bills according to the fee schedule, and that amount is sometimes higher. You would be responsible for the difference.

The state associations of psychotherapists consider this cap to be unlawful. Section 13(3) of SGB V refers to reimbursement in the amount actually incurred, which is determined by the treatment contract. The valuation standard is binding only on practices that have entered into a contract.

You can point out this contradiction yourself; the practice can provide you with the figures to back it up. Before you argue about it, however, make sure there actually is a discrepancy. There are practices for which the health insurance rate is acceptable, and in those cases, the issue can be resolved with a phone call.

The most recent publicly available figure comes from the German Association of Psychotherapists: one Online Survey among its members in private practice, published in February 2022 and conducted in October 2021, with 503 participating psychotherapists. The rejection rate for initial applications rose from 43 percent in 2019 to 48 percent in 2021.

Filing an appeal is more often successful than the rejection rate would suggest. In 2021, 44.8 percent of patients filed an appeal, and only 29.8 percent of those appeals were rejected. In 38 percent of medical practices, the first appeal is even always successful. That is the encouraging figure from this survey.

The health insurance companies’ justifications are repetitive, and the survey measures them: 79 percent of practices report being referred to the appointment service center, 64 percent report being told that there are enough contracted psychotherapists, and 59 percent report that the insurance company claimed reimbursement is no longer permitted.

For three years, I handled these claims from my private practice because, without being enrolled with a health insurance provider, there was no other way to bill patients. The reimbursement process is bureaucratic—that’s the most honest way to describe it. Still, the effort involved remains manageable; there are only a few steps, and the key is to complete them correctly.

Keep a record starting with the first rejection, even if you’re still hoping you won’t need to file a claim for reimbursement. It doesn’t take long to write three lines after each phone call, but reconstructing the details from memory does.

And if someone tells you that this procedure no longer exists—that’s not true. This information comes strikingly often from the health insurance provider itself, not from the doctors’ offices, as the figures above show. The entitlement under § 13(3) of Book V of the Social Code (SGB V) remains unchanged in the law, and it applies to any psychotherapy that is necessary but not covered by the health insurance system.