The standard maximum fee rate in health insurance: GOÄ factors explained

Private medical services are billed under the fee schedule for doctors. Each service has a number with a fixed point value. The doctor multiplies the simple rate by a multiplier. Under § 5 GOÄ, this multiplier should reflect the difficulty, the time required and the circumstances of the treatment. The standard maximum rate marks the limit up to which this assessment is allowed without further explanation.

In practice, most doctors bill personal services at 2.3 times the rate as standard. This factor is therefore the normal price of private medicine in practice, not the exception. For dentists, the fee schedule for dentists (GOZ) sets its own rules with the same logic: standard rate 2.3 times, maximum rate 3.5 times with a written reason.

The GOÄ sets different ranges depending on the type of service:

Above the maximum rates, a doctor can only bill through an individual fee agreement signed before the treatment. Such agreements are common with sought-after specialists and chief physicians. They are the most common reason for large, unexpected out-of-pocket shares.

In private health insurance, the standard maximum rate works through the plan conditions. Many standard and entry-level plans only reimburse doctors' fees up to 2.3 times the rate. Comfort and top-tier plans reimburse up to 3.5 times, and some top-tier plans even more.

The math behind it is simple. If the doctor's bill is above the fee rate agreed in the plan, the insurer pays up to its limit, and the policyholder pays the rest. For a larger operation with a written reason under § 6 GOÄ, the difference between 2.3 times and 3.5 times can amount to several hundred euros. The reimbursable GOÄ factor is therefore one of the most important points of comparison in any set of plan terms, well ahead of many comfort components.

If a doctor wants to bill above the standard maximum rate, the bill must contain a written reason that refers to the individual case. Examples are an unusual amount of time, a special difficulty of the service or complicating circumstances on the part of the patient. If the reason is missing or consists only of standard phrases, the extra amount is not due. The patient may refuse to pay the part above the limit and ask for a corrected bill.

Privately insured people are not alone in this. Insurers check submitted bills systematically and object to unjustified amounts above the standard rate on their own initiative. If you pay a bill first and then submit it, you should therefore wait for the insurer's check before you transfer disputed extra amounts.

From our advice work we know that hardly any plan feature is underestimated as much at signing as the reimbursable GOÄ factor. And hardly any becomes so unpleasant when you make a claim.

For insured people who often see specialists or go to clinics, we recommend that you budget for a plan that reimburses up to 3.5 times the rate when you choose. A single specialist treatment per year often pays for the extra premium. If you mainly see your family doctor, a plan with 2.3 times the rate usually works well. You should still know the limit before your first appointment with a chief physician.

Yes, through the GOZ. There too, the standard rate is 2.3 times, and the maximum rate that requires a written reason is 3.5 times. Agreements above the maximum rate are common, especially for dentures and implants. Your own dental plan decides what of this is reimbursed.

Yes, for elective physician services. If you agree to chief physician treatment, you are billed for the medical services under the GOÄ, with the same standard and maximum rates. General hospital services, on the other hand, are billed under the Hospital Remuneration Act (KHEntgG).

No, not formally. Under § 5 GOÄ, the factor should reflect the actual effort. A simple routine case belongs below the threshold of 2.3 times the rate in arithmetic terms. In practice, 2.3 times the rate has become the standard, and insurers accept it at this level.

Before you sign, check your own plan and ask your insurer whether it reimburses and up to what amount. Only a few top-tier plans cover fees above 3.5 times the rate. Everything else is an extra private payment you make knowingly.