In Germany, hip and knee prosthesis operations are common procedures for restoring the mobility and quality of life of patients with advanced joint diseases. While such interventions are traditionally carried out in public hospitals, more and more patients are considering treatment in private clinics. However, a widespread misconception states that private clinics are only reserved for private patients. In fact, under certain conditions, legally insured persons can also benefit from the services of a private clinic, in particular through the procedure for the transfer of individual costs.

In this comprehensive guide, we will explain the concept of individual cost transfer in detail, describe the process of applying for the statutory health insurance companies for hip and knee prosthesis operations in private clinics and show how patients such as they can make use of this option.

What is an individual assumption of costs?

The individual cost transfer is a procedure in which the statutory health insurance company covers the costs of medical treatment in a facility that does not have a supply contract with the statutory health insurance companies, as is often the case with private clinics. This means that the health insurance company pays the treatment costs in the private clinic up to the amount of the costs that would have been incurred in a public hospital. Any additional costs must be borne by the patient himself.

This procedure enables legally insured persons to claim services that may not be included in their regular service catalog or are provided in facilities that are not part of the standard network of statutory health insurance.

Requirements for the individual cost transfer for hip and knee prostheses

In order to obtain an individual cost for a hip or knee prosthesis surgery in a private clinic, certain requirements must be met:

1. Cost neutrality : Treatment in the private clinic must not be more expensive than in a public hospital. The statutory health insurance only covers the costs that would also have been incurred in a public facility. Any additional costs, such as B. for a single room or additional services, must be worn by the patient himself.
2. Medical necessity : the operation must be medically necessary and meet the guidelines of statutory health insurance.
3. Missing treatment options : In some cases, individual costs can be approved if the required treatment is not available in a public hospital or in sufficient quality.
4. Previous approval : The patient must apply to his health insurance company before the start of the treatment and wait for approval. Without this prior consent, there is no claim to reimbursement.

The application for a transfer of individual costs: step-by-step instructions

The process for applying for a single cost transfer can appear complex, but with the correct preparation and procedure you can increase your chances of approval. Here is a detailed guide:

1. Consultation with the treating doctor : Discuss the possibility of an operation in a private clinic with your orthopedic surgeon or surgeon. Let yourself be explained by the medical necessity and the advantages of treatment in the selected facility.
2. Obtain the cost estimate : Request a detailed cost estimate from the private clinic, which lists all the expected costs of the treatment. This should be comparable to the usual costs in public hospitals.
3. Application to the health insurance company : Submit the cost estimate together with an informal application for assumption of costs with your statutory health insurance company. Justify why the treatment should take place in the private clinic and add all relevant medical documents.
4. Waiting time and inquiries : The processing of your application may take a few weeks. Stay in contact with your health insurance company and answer any questions immediately.
5. Waiting approval : only start the treatment if you have received a written approval of your health insurance company. Without this consent, you have the financial risk yourself.

Advantages of treatment in a private clinic

The decision for treatment in a private clinic offers several potential advantages:

• Individual support : Due to a lower number of patients, private clinics can often offer more personal and intensive care.
• Specialization : Many private clinics specialize in certain specialist areas and have experienced specialists, which can lead to better treatment results.
• Comfort and equipment : private clinics often offer upscale equipment and additional comfort, such as: B. single rooms or special services.
• Flexibility in appointments : With a tighter organization, shorter waiting times and more flexible appointments can often be realized.



Frequent misunderstandings and clarifications

There are some common misunderstandings regarding the treatment of legally insured persons in private clinics:

• Myth: Private clinics are only for private patients : The fact is that legally insured persons in private clinics can also be treated, provided that the assumption of costs has been clarified in advance.
• Myth: High additional costs for legally insured : If the health insurance company approves the individual costs and the treatment costs correspond to those in public hospitals, there are no or only low additional costs for the patient.
• Myth: Complicated application process : With the correct preparation and support of the attending doctor, the application process is manageable and easy to manage.