Even three years after the introduction of digital health applications (DiGA), the “apps on prescription” are not always running smoothly. In the past few months, health insurance companies have repeatedly contacted their policyholders and either rejected medical DiGA prescriptions or requested medical justifications.
This should come to an end: The Federal Office for Social Security explains the legal situation in a letter to all federal health insurance companies: For DiGA with a doctor’s prescription, the therapeutic sovereignty of the doctors and the care entitlement of the patients apply. Prescribed relevant apps are not subject to approval by the health insurers.
“DiGA are prescribed product-related by the treating doctor or treating psychotherapist,” quotes the Berlin company Vivira, which offers an app for back pain, from the letter. It is therefore up to the doctor or psychotherapist to check “whether the services are sufficient, appropriate, necessary and economical”. “Not only medical standards” are decisive, but also “economic efficiency” and other exclusion criteria.
In view of the doctor’s freedom of therapy, the health insurance company is fundamentally prohibited from “intervening in the doctor’s prescription decision”. With the relevant legal regulations, the determination of the price system for DiGA at the umbrella association level, and the directory maintained as a positive list at the Federal Institute for Drugs and Medical Devices, an exception to the approval requirement by the health insurance company has been created, the Federal Office emphasizes.
“Due to the circumstances”, it also points out that the insurers are also not entitled to switch to other, possibly cheaper DiGA if there is a doctor’s prescription.
Expensive Apps
Vivira founder Philip Heimann evaluates the announcement as an “important signal” for doctors and patients. Individual health insurance companies “unnecessarily delayed or even refused” activation codes.
As early as 2019, the Bundestag determined with the Digital Care Act that people with statutory health insurance are entitled to digital health applications by prescription under certain conditions. At the beginning of the year, the statutory health insurance companies often considered DiGA to be dispensable and saw no breakthrough in relevant apps. They complain about their high costs.
The Free Medical Association criticized 2021: Although DiGA “no benefit has to be proven, the statutory health insurance companies pay 500 euros for an obesity app for 90 days, for example. That is more than a statutory insured person on average for the entire outpatient medicine including all medical and technology – and laboratory services per year costs.”
