(08/2022) Who Dr. Bastian Reuter (Hackstein Reuter Rechtsanwälte law firm) from various specialist articles and online seminars - including for the MTD publishing house - knew one thing for sure: the lawyer will provide up-to-date information on SSB matters in Cologne on the occasion of the ZMT Infotage 2022. And so it happened. The positive and negative facts were roughly balanced. The most recent court judgments spread glimmers of hope here and there, as the payers keep coming up with new "nice things" in order to score points on the recourse floor.
Before Dr. Reuter dealt with the current – and definitely exciting – developments at the SSB, he briefly went into the two common procurement and sales systems at the SSB. A distinction is made here according to areas with supply contracts "in various forms" between health insurance companies and suppliers and areas without supply contracts.
Territories with supply contractsThese contain regulations regarding prices and billing methods. In addition, there is usually a general obligation to comply with the principle of economic efficiency, which according to Dr. Reuter can be regulated “often in one sentence, but sometimes also in a wide variety of forms”, or can also contain a specific obligation for the supplier to make a selection decision between several articles, taking into account the principle of cost-effectiveness.
According to Dr. Reuter is that the supplier has a contractual right to remuneration from the health insurance company.
Territories without supply contractsThe legal situation for SSB suppliers is completely different if there is no supply contract. The doctor prescribes and purchases the products and assigns his right to reimbursement to the supplier. This then settles the bill with the health insurance company.
Exactly at this point, however, there is now a great deal of legal uncertainty. The status quo here is the contentious and open legal question of whether there is even an independent claim for remuneration on the part of the supplier against the health insurance company from the guarantee function of the contract doctor's prescription. The health insurance companies often oppose this and deny it.
Judgments give hopeHowever, movement is now coming into play here, because two more recent LSG judgments argue in favor of SSB suppliers, according to Dr. reuters Tenor: A payment claim by the supplier against the health insurance company does not require a supply contract. The service provider can nevertheless assert a direct payment claim against the health insurance company via the guarantee function of the doctor's prescription.
Another related benefit for SSB suppliers, according to Dr. Reuter said that any reductions in health insurance against the SSB Liefera
