In the event of a case, specific practical details must be explained in detail

Darmstadt. In order to assess possible practice-specific characteristics, the review panels are permitted to use a so-called prevalence assessment. However, in the event of a dispute, physicians are still required to provide substantiated evidence of their practice-specific characteristics. This was the ruling of the Hessian State Social Court (LSG) regarding an examination in Hesse (case number: L 4 KA 1/23).

In the prevalence assessment, the prevalence of the disease relevant for a billing code in the practice's area is compared with the usual prevalence. If the code is higher in the practice's catchment area, this may be grounds for the assessment body to recognize certain excesses.

Specialist group average significantly exceeded

The plaintiff in the case now decided by the State Social Court – a general practitioner – had billed GOP 35110 (Verbal Intervention in Psychosomatic Conditions) in 2015, depending on the quarter, 500 to 700 percent more frequently than the specialist group average. The total fee claimed for this amounted to €21,145.

The examining body asked the physician to disclose the specifics of his practice. He pointed out, in particular, the high proportion of patients with a migrant background.

In addition, the examination board conducted a prevalence assessment, the results of which showed deviations of approximately 100 percent. Overall, the examination board awarded the physician a premium of up to 200 percent for GOP 35110 compared to the specialist group average. Accordingly, it reduced the requested fee for the four quarters of 2015 by a gross amount of €12,271. The appeals committee confirmed this.

Special features not presented thoroughly enough

In his lawsuit, the doctor specifically criticized the prevalence assessment. He argued that this was case-specific, but GOP 35110 could be billed multiple times per case and patient. He was successful in this case before the Marburg Social Court. However, the Darmstadt Regional Social Court dismissed the lawsuit.

In their justification, the judges stated that the review panels had ultimately used the prevalence assessment only as a starting point for an anomaly assessment. This was not objectionable.

Rather, the physician could have presented his practice's unique features in order to "obtain more significant recognition of his practice's uniqueness." However, in the opinion of the Higher Social Court, such a substantiated explanation of the practice structure "even with the aid of statistical analysis by the physician" was omitted.

The mere fact that a certain number of patients with F diagnoses were billed disproportionately frequently under EBM number 35110 does not indicate a particular patient structure within the practice. "Rather, it could also indicate an uneconomical billing scheme, in which the physician unnecessarily treats the deviant clientele beyond what is necessary," the LSG stated. (mwo)