Applying for an Inpatient Rehabilitation Program ("Rehab")
A) For Persons with a Statutory Health Insurance
1. Legal Basis
The legal basis of a rehabilitation are defined in the first, fifth, and ninth German Social Code Book (SGB I, SGB V and SGB IX). Patients are eligible for an inpatient rehabilitation program, if the medical treatment or the outpatient rehabilitation measures are not sufficient to detect, cure or prevent a disease from deterioration, or to alleviate disease-related symptoms.
In most cases, the statutory pension insurance (employed persons etc.) or the statutory health insurance (retired persons etc.) are the appropriate service providers for inpatient rehabilitation measures. Eligible are certified rehabilitation facilities which either have a supply contract with the corresponding health insurance, in accordance with § 111 SGB V, or an occupancy agreement with the statutory pension insurance, or are part of their sponsorship. The Lympho-Opt clinic meets those conditions. Should the insured person select another setting, he/she has to bear any additional costs arising from this choice.
Inpatient rehabilitation measures are only granted once every four years, unless medical reasons urgently require a prematurely rehabilitation.
A further precondition could be that the inpatient rehabilitation program might show some treatment success. In this case the need for as well as the target and potential of such a rehabilitation must be evaluated by the service provider prior to starting the treatment (statutory pension insurance, health insurance or medical service on behalf of the corresponding health insurance).
2. Application Process
Prior to your inpatient rehabilitation you have to contact your responsible payer and apply for the program. Please contact your local health or pension insurance; they will inform you on the relevant contact in your case. They will also provide the appropriate application forms (Health insurance: model form 60 and 61, pension insurance: application form G100). Please ask your doctor (if possible a specialist) to fill in the corresponding forms and to issue a positive opinion (medical report). Should multiple diseases exist simultaneously, the application must list the leading diagnosis in the first place
. Should the leading diagnosis not be "secondary arm lymphedema stage II" or "distinct lipedema with strong pain", the prospect of being granted a rehab at a lymphologic specialist clinic is rather low.
The medical certificate is of utmost importance for the issue of a rehab applicationt.
If you want your rehab to be a measure for the treatment of a disease (§ 40 sect. 2 SGB V), the certificate must clearly define the aims of this rehab:
- Detect and cure a disease
- Avoid a deterioration of the disease
- Alleviate disease-related symptoms
- Prevent a threatening disability
- Eliminate or reduce a disability
- Avoid the deterioration of a disablitly
- Avoid or reduce long-term care
If you want your rehab to be a measure on disease prevention (§ 23 sect. 4 SGB V), the objective of this rehab could be the elimination of a health-related weakening which, in the foreseeable future might lead to a disease.
The medical opinion (medical report) must follow the criteria of approval, issued by the MDK:
a) Need of Rehabilitation
Are bodily functions and body structures damaged or impaired, which affect the applicant in operations (activities) and participation? Is his/her performance significantly reduced or at risk? For the purpose of determining the need of a rehab, the following information is required:
- Symptoms and disorders, history, chronification, disability to work
- Impairments of body functions and structures
- Lifestyle and disease risk factors
- Motivation, ability of insight, coping with the disease
- Degree of information and training
- Occupational stress and dealing with situations of daily life
- Threat of job loss, social support, request for pension due to reduced earning.
b) Capability for Rehabilitation
Is the applicant physically and mentally stable enough to receive the whole offer of the therapeutic services? Is he willing to undergo the treatment?
c) Prognosis of Rehabilitation
Will the desired objective of rehabilitation most likely be achieved? The prognosis of rehabilitation is closely linked with the capability of a rehabilitation, for example in the area of motivation.
d) Objective of Rehabilitation
Improvement of the functional health respectively prevention of their impairments by adaptation of the remaining skills and learning of compensational options.
e) Failure to Comply with the 4-Year Period
According to § 40 sect. 2 SGB V, a rehab usually cannot be granted before the expiry of 4 years after implementation of the relevant rendered services. In case of urgent and necessarily required health reasons this regulation can be bypassed. Those health reasons could be:
Significant limitation / reduction / risk of
Significant risk / high probability of occurence / impairment of
- Availability for work assignment
- Earning capacity
- Occupational capability
- Daily independence
- Independent housekeeping
- Acceleration of the disease
- Current functional reserves
- Aggravation of the disease
- Heavy / severe disability
- Increased need of long-term care
- Significant functional limitation
- Independent housekeeping
- Mental disorder or stress
- Deterioration of the quality of life
f) Deviation from the Principle "Outpatient Prior to Inpatient"
Inpatient measures shall only be approved in accordance to the law, if outpatient measures are not adequate, do not show the desired success or for other reasons, e.g. due to non-existing on-site availability or if they cannot be performed due to family obligations. The necessity as well as the focal points of an inpatient rehab have to be justified. Reasons for this could be: the previously prescribed outpatient measures have been exploited and are no longer sufficient or that, based on the exisiting clinical picture a bad prognosis is to be expected. An inpatient rehab guarantees a demand-oriented lymphological treatment, as the required time and the professional assistance for processing and managing causes and impacts of the disease are given.
3. Right of Choice
If you want to choose a specific clinic for your rehab, you must specify this in the application form. In accordance with § 9 SGB IX, § 76 SGB V, § 13 SGB VI and § 33 SGB I, you yourself are entitled to choose a rehabilitation clinic which is suitable for you. This regulation intends to promote your self-determination as a patient, and grant you as much space as possible during the rehab to autonomously create your living conditions. The German Society for Medical Rehabilitation specifically indicates this point.
4. Application Rejected - What Comes Next?
Once the payer has received your application, he usually forwards it to the medical services of the health insurance (MDK) for verification. If the MDK acknowledges the medical necessity of your rehabilitation, your request will be accepted. As many MDK experts do not have a solid knowledge of diseases which affect the lymphatic system, they often reject those applications of lipedema and lymphedema patients, claiming that, with a higher dosage of the application patients can be treated well on an outpatient basis. Of course there can also be other reasons for the rejection.
The notice of rejection must be in writing. It must furthermore contain an explanation of legal remedy and indicate an exact deadline, until when the payer must have received the objection. In order to meet the deadline, you may write the following statement to your health insurance: "Against your decision dated... I herewith file an objection. Justification to follow". Should the notice of rejection not mentioned a deadline, you have one year to draft your objection.
Sometimes a direct telephonic conversation between your medical specialist and the MDK expert is sufficient to clarify and eliminate the reasons of a rejection. If not, you can also insist on an examination, done by one of the MDK physicians. As this physician usually only decides on the basis of records, a personal visit might change his opinion.
5. Lawsuit before the Social Court
Should the health insurance furthermore insist on the rejection of your application, despite of your objection, you can file a lawsuit at the Social Court. This must be received by the court within one month upon receipt of the written notification of opposition. There is no formal requirement for the lawsuit. It should, however, at least contain what you have applied for at the payer as well as an explanatory statement.
Bei Verfahren vor Sozialgerichten fallen keine Gerichtsgebühren an. In proceedings before social courts usually no court fees incur. In addition, the State has to take over all costs for experts and witnesses ("Principle of official investigation"). The person losing the proceeding, however, has to take over the attorneys' fees. With regard to lawyer's fees, the law has defined sliding-scale fees. Lawyers usually charge an average:
1. Instance (Social Court) 50 to 600 €
2. Instance (Regional Social Court) 60 to 780 €
3. Instance (Federal Social Court) 90 to 1300 €. .
In the first two instances the representation by a lawyer is not mandatory. You can conduct your own case, though this usually makes little sense. Should you possess a private legal protection insurance, disputes before social courts are covered, however, not those costs your lawyer charges for his work in the opposition proceedings. Should the legal protection insurance not guarantee coverage and, provided your financial situation permits this, you may also qualify for legal aid. Some trade unions provide legal protection for their members who experience social disputes.
B) For Privately Insured Persons
The private health insurance classifies the Lympho-Opt Clinic as a mixed hospital, according to § 4 sect. 5 MB/KK. Privately insured patients can be hospitalized for acute clinical treatment, if they own a referral from their general practitioner which has been pre-approved by their health insurance. Upon consultation with their health insurance they can also participate in the Lympho-Opt inpatient rehabilitation program. According to § 6 and § 7 BHV, Lympho-Opt is an eligible clinic.
In any case and prior to admission, privately insured patients or direct payers have to present a corresponding declaration that costs for an inpatient rehab will either be paid by themselves or are covered by the payers (health insurance, aid).