Will private health insurance be turned upside down?

The German medical fee schedule (Gebührenordnung für Ärzte, GOÄ) is to be amended – read on to find out what the amendment entails for private health insurance (PHI) and the insurers providing it.

Gebührenordnung für Ärzte

GOÄ amendment: classification and strategic significance for private health insurance

The German medical fee schedule GOÄ is a central element of the PHI plan structure: it regulates the billing of medical services to privately insured patients and defines the invoicing fee rates for patients with full or supplementary insurance coverage. For the first time in almost three decades, the GOÄ is facing a fundamental revision. The envisioned amendment represents a significant milestone in terms of both medical care and the billing thereof – with far-reaching consequences for private health insurance. It will affect over 8.7 million privately insured persons, around 31 million people with supplementary health insurance and the entire individual healthcare services market (individuelle Gesundheitsleistungen, IGeL) for self-paying patients with statutory health insurance.

Contents of the GOÄ amendment

The planned GOÄ reform comprises numerous structural and content-related changes:

  • A modern assessment model incl. new definitions and application rules to align the GOÄ with the current state of medical knowledge.
  • A detailed service directory containing over 5,600 items to cover a wide range of specific services.
  • Elimination of factor increases, instead introduction of hardship allowances.
  • Continuous ongoing review and updating by a joint commission of the German Medical Association (Bundesärztekammer), the German Association of Private Health Insurance (PKV-Verband) and the offices responsible for health insurance subsidy.

The starting signal has been given – what happens next

At the 129th general assembly of the German Medical Association in May 2025 (Bundesärztetag), after years of intensive preparation and negotiations between the German Medical Association and the PKV-Verband, a clear majority decided in favor of submitting the jointly developed draft to the Federal Ministry of Health. This constitutes the starting signal for the GOÄ amendment and paves the way for the next steps in reforming the private medical billing system.

The Federal Ministry of Health is now in charge of implementing the draft. When exactly it will enter into force remains to be seen as further coordination is required. 

Implications for private health insurers

The new medical fee schedule fundamentally changes the billing logic and the underlying calculation principles. The previous principle of factor increases – for example with a 2.3 or 3.5-fold rate – will be replaced by a new system of hardship allowances. This has the following implications for product development: Plan lines that were previously based on fixed rates of increase have to be adjusted and the calculation models revised accordingly.

In addition, the new model necessitates simulating the effects of the new fee schedule on benefit expenditure and to adjust the benefit policy. Accompanying forecasts by the German Medical Association and the PKV-Verband suggest an increase in expenditure of 13.2 percent within the first three years.

But the implications for private health insurers go beyond that: the changes to medical invoicing also affect the requirements for document readout and automated claims processing. Input management and regulations must be adapted accordingly. The people responsible for processing are also facing radical changes – after decades of working with the same GOÄ structures, they have to adjust their verification procedures as well as other processes and take part in trainings to familiarize themselves with the new rules.

„The upcoming amendment to the German medical fee schedule poses considerable challenges for insurers. Only those who recognize its impact early on and react strategically lay the foundation for successful further development."
 

Mirko Theine, Senior Manager

One thing is clear: the GOÄ amendment has far-reaching consequences – not only for physicians and their patients, but also for insurers.

We are convinced that dealing with the new regulations in good time ensures a smooth transition from the old to the new fee schedule.

Further insights into the GOÄ amendment and its relevance for the insurance industry can be found in a current article from the AssCompact magazine (only in German).

Status: July 2025

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Mirko Theine

Senior Manager

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Kilian Gundlach

Senior Manager