Will my private insurance cover the house call?

How private insurance pays for a house call

Privately insured patients receive a GOÄ invoice after every house call — issued by our private medical billing service a few days after the visit. The invoice lists each individual service with its tariff code, multiplier and euro amount. You submit it to your insurer by post, app or customer portal and receive reimbursement, typically within 5 to 15 working days, to your bank account. Most full ambulatory policies reimburse 100 percent, including the house-call codes and any out-of-hours surcharges under GOÄ.

But there are three classic pitfalls. First: some tariffs cap the reimbursable GOÄ multiplier — for example only up to 1.8 or 2.3. If the doctor applies 2.8 or 3.5 for justified extra effort, the insurer reimburses only up to the tariff ceiling and you carry the rest. Second: some tariffs include a deductible — typically 300 to 1500 euros per year — that a house-call bill consumes first. Third: civil servants on Beihilfe (federal/state employees, judges, soldiers) receive 50 to 80 percent from the Beihilfe office depending on their rate, with the remainder paid by their supplementary PKV — the two reimbursements arrive separately and at different speeds.

In practice: with a standard full PKV policy a house call is economically identical to a practice visit — the insurer pays everything, you get the full bill back. With reduced tariffs, factor caps or Beihilfe it pays to read the tariff sheet before the first visit. On the phone we are happy to give an honest range of the multiplier we expect to apply, so you have no surprises. And: even if your insurer rejects a portion, there is no double-payment risk. The bill is yours, not the insurer's — and itemised transparently under GOÄ.

Example: Beihilfe-entitled civil servant from Friedrichshain

A 52-year-old federal civil servant with 50 percent Beihilfe entitlement and a 50 percent supplementary PKV calls on a Sunday with acute bronchitis. The house call costs 290 euros under GOÄ. He first submits the bill to the Beihilfe office — within ten working days 145 euros arrive. He submits it in parallel to his PKV — within a week another 145 euros arrive. End result: full reimbursement, no out-of-pocket. If his tariff had capped the factor at 2.3 and the doctor had used 2.8, he would have carried the difference — typically 20 to 40 euros.

What your tariff typically covers — and what it doesn't

• Full policy (PKV ambulatory 100 %): usually full reimbursement — visit, examination, travel fee, out-of-hours surcharges.
• Tariffs with factor cap: often covered up to factor 2.3 or 3.5 — the doctor must justify higher factors in writing.
• Tariffs with deductible: you carry the annual deductible first, then full reimbursement.
• Beihilfe + supplementary PKV: Beihilfe rate (50 – 80 %) plus PKV remainder — separate claims.
• Travel insurance: usually covers acute house calls for foreign visitors — we provide a doctor's certificate for the insurer.
• Standard tariffs include house calls — the German PKV system has no 'house call rejected' category.
• If in doubt: call your insurer beforehand and ask about the factor cap — we give you the expected codes on the phone.