Finding a therapy place in Frankfurt. The Kostenerstattung route.
Even with statutory health insurance you can be treated at a private practice. The route for it is called Kostenerstattung, under § 13 (3) SGB V.
If your Krankenkasse (your statutory health insurer) cannot find you a therapy place within a reasonable time, it can cover the cost of private treatment. The application is paperwork, it has to be submitted before treatment begins, and it is not always granted. But it is a regular route, and it is manageable.
What this is about and where it usually fails.
Your Krankenkasse is obliged to make necessary treatment available to you. If it cannot, because no place is free within reach, a gap opens up that the law knows about and that this provision exists for.
This is not a favour and not a special dispensation, it is an entitlement. But it is an entitlement you have to evidence. The burden of proof lies entirely with you, and that is exactly where most applications fail.
That is why this text is so detailed. If you work through the four steps properly, your application will be better than average.
Four steps, in this order.
-
The Sprechstunde and PTV 11
It all begins with a psychotherapeutic initial consultation (psychotherapeutische Sprechstunde) at a practice that bills the statutory health insurers. There it is established whether you have a condition that needs treatment and how urgent treatment is. An appointment is arranged by the appointment service on 116 117, by phone around the clock, or online at 116117.de. At the end you receive form PTV 11. It states whether psychotherapy is recommended and with what degree of urgency. Without this form there is no application.
-
The Konsiliarbericht
Your GP, or a specialist practice where appropriate, fills in a Konsiliarbericht, a physician's accompanying report. It records whether physical causes for your symptoms need to be considered and whether, from a medical point of view, anything speaks against psychotherapy. Practices know the form; if not, I give it to you to take along. Allow one to two weeks and make the appointment early. In my experience this is the point at which applications get stuck.
-
Documenting rejections
You have to show that you searched seriously. No law names a number; in practice the Krankenkassen usually expect three to five documented rejections from practices that bill the statutory health insurers, some of them more. For every enquiry, note four things: the date, the name of the practice, how you made contact, and the answer you received. An entry then looks something like this: 12 March, Dr Schneider's practice, by phone, no places free, waiting list closed. A message on an answering machine counts too, as long as you record the date, the time and the wording. Save email replies as PDFs. And also document what 116 117 did for you, including the reference number.
-
The application itself
The application goes to your Krankenkasse in writing and consists of five parts: an informal covering letter in which you apply for the costs to be covered and briefly describe your situation; the PTV 11; the Konsiliarbericht; your list of rejections together with the evidence; and my therapist's certificate. Added to that is a statement of the expected costs under the German fee schedule for psychotherapists (GOP). One point is decisive: submit the application before treatment begins. As a rule, costs are not reimbursed retrospectively. And only guideline psychotherapy (Richtlinientherapie) is reimbursable, that is, short-term or long-term therapy. A Sprechstunde or an acute treatment on its own is not.
-
1–4
weeks
Until the psychotherapeutic Sprechstunde.
-
1–2
weeks
For the Konsiliarbericht. Make the appointment early.
-
2–4
weeks
To collect and document the rejections.
-
3–5
weeks
The insurer's decision. Realistically it is two to three months until you have an answer.
Three weeks for the insurer, one month for your appeal.
Your Krankenkasse has to decide within three weeks. If it brings in the Medizinischer Dienst, the insurers' medical review service, it is five weeks, and it has to tell you that in advance.
If it lets this deadline pass without giving reasons, a so-called Genehmigungsfiktion (deemed approval) can arise under § 13 (3a) SGB V. Whether an enforceable entitlement follows from that has to be examined case by case. The provision does work, but it only helps if you can prove when your application arrived. So send it by registered post or through your insurer's portal with confirmation of receipt, and note down the date.
Expect a refusal. Of the first applications, around half were refused most recently. A refusal does not mean your case is unjustified, and it is not the end of the road. On this route the appeal is often simply part of the procedure.
From the date you are notified of the decision you have one month to lodge a written appeal (Widerspruch). It should contain: a reference to the decision with its date and file number; a response to the specific reasons the Krankenkasse gave; your rejection list, by now longer; a reference to the urgency noted on the PTV 11; and, if your condition has worsened, a current medical statement.
If the appeal is unsuccessful too, the way to the Sozialgericht (the social court) is open; those proceedings are free of court costs for you. Whether that step makes sense is best discussed with a social welfare association or a solicitor specialising in social law. Giving legal advice is not something I am allowed to do, and not something I want to do.
If it doesn't work out, here are the numbers.
- Individual session, 50 minutes Billed under the German fee schedule for psychotherapists (GOP), at 2.3 times the standard rate. The amount depends on which services the session involves. 134.06–167.58 €
- Individual session, self-pay 50 minutes, with no insurer involved. 167.58 €
- Couples therapy, 90 minutes A pure self-pay service, including VAT. 220 €
Your contract is with me, not with your Krankenkasse. The invoice goes to you, and you claim the reimbursement afterwards. You make that decision before we start, not in the middle of a therapy. I tell you beforehand what costs you realistically have to reckon with.
Asked briefly, answered briefly.
How many rejections do I really need?
Can I start therapy while the application is being processed?
Does Kostenerstattung also apply to couples therapy?
You don't have to get through this paperwork on your own.
I issue the therapist's certificate. It documents that I am a Psychologische Psychotherapeutin with an Approbation, the German state licence to practise, that I hold the qualification in cognitive behavioural therapy, and that I meet the professional requirements for a Kassenzulassung. I give you templates for the covering letter and the rejection list, explain the decision to you when it arrives, and support you with the appeal. In German, in English and in Farsi.
Request an appointmentI cannot assure you that your Krankenkasse will agree. Nobody can. What I can promise is that your application is complete and properly reasoned.