Binding dentist costs?

Binding dentist costs?

Unfortunately, it is not uncommon in everyday patient life: A patient finds that his dentist bill, for example for a bridge in the upper jaw, turns out to be much higher than was foreseen in the cost estimate. If the cost estimate still contained growth factors of 2.3 and 3.0, the practice now calculated the 3.5 times the rate and in two positions even the 4.0 times the rate. Very annoying for the patient. Because the cost estimate should serve the financial planning security.

But it is not only with the personal contribution for dentures that insured persons with statutory health insurance (GKV) can experience unpleasant surprises regarding the final bill. Also in the case of therapies that allow an additional payment in addition to the health insurance, e.g. more complex dental fillings (additional cost agreement in accordance with Section 28 Paragraph 2 SGB V), or in the case of pure private services, such as implantations, there may be differences between the cost estimate and the invoice. In these cases, the services are to be rendered privately according to the fee schedule for dentists (GOZ), which allows a relatively large scope for fees, since dental services can be calculated between 1 and 3.5 times the fee. Even fees with a factor over 3.5 times are possible, but must be agreed with the patient in writing before the start of treatment in accordance with Section 2 Paragraphs 1 and 2 GOZ. Services that are charged over 2.3 times the fee rate must be justified in the invoice (Section 10 (3) GOZ).

Quotation binding?

So how binding is a medical and cost plan (HKP)? Can the amount agreed in writing with the patient be exceeded or is it an upper limit? This question can only be answered taking into account the different perspectives. According to the German Civil Code (BGB), healing and cost plans (cost estimates) are only a non-binding calculation of the costs that are likely to arise by means of contract initiation. There is therefore no price guarantee. On the contrary, the costs stated on the later invoice may well be higher than the amount that was calculated in the estimate. Of course, this cost increase must not climb to astronomical heights (§ 650 BGB). As a rule of thumb, one can deduce from the current case law that the patient must tolerate exceeding up to 20 percent of the originally estimated costs. In the event of major deviations, the dentist must inform the patient in good time that the invoice significantly exceeds the cost estimate.

However, the district court of Hanover (judgment of 29.10.1998, 119 S 9/98) decided that a healing and cost plan drawn up by the dentist for a denture treatment is binding, unless unforeseen and unforeseeable difficulties arise during the course of the treatment. In contrast, the material and laboratory costs can be estimated in the healing and cost plan for a prosthetic treatment. This view was later confirmed in principle by the 12th Civil Senate of the Brandenburg Higher Regional Court. In their judgment (judgment of 14.09.2006 – Az. 12 U 31/06), the judges assume that the dentist is in a position, before the start of the planned treatment and when the treatment and cost plan is drawn up, to do so regularly to provide an overview of the services rendered. He is therefore obliged to break down the dental fee that will be charged for his services as precisely as possible in advance. This enables the patient to make his or her decision as to whether the dentist should perform the treatment in the intended manner. If the dentist did not have to adhere to the cost estimate he created, it would be worthless for the patient and financial planning would not be possible.

But be careful: the Brandenburg judges also allow an increase in the dentist’s fee estimated in the treatment and cost plan. Namely whenever there are unforeseeable difficulties for the dentist in the course of the treatment – despite previous diagnosis. If, on the other hand, the dentist is already aware of special features that may make treatment difficult, then these special features must be taken into account in the cost estimate or the patient should be informed that a higher fee may apply later (Cologne Higher Regional Court, judgment of October 23. 1996, Az. 5 U 52/96, LG Krefeld, judgment of 17.07.1992, Az. 1 S 36/92).

With many cost estimates, important information for the patient regarding the expected costs can often only be found at the end of the cost estimate:

“Costs for general and conservative surgical services according to the GOZ are not included in the amounts.” (Dental prosthesis treatment and cost plan – part 2 for SHI insured with identical or different types of care)

"Preservative, surgical or other services that may be necessary will be invoiced according to individual effort". (Estimate for private treatment)

Fees for these treatments are therefore not included in the cost estimate! Whenever this or a similar wording is on the estimate, the patient should ask the dentist what additional services are required and, if necessary, request a further estimate.

Separation between dental fee and material / laboratory costs

If the invoice exceeds the estimated costs in the treatment and cost plan and the invoice includes not only dental fees, but also material and laboratory costs, the costs must first be separated into the dentist’s fee and material and laboratory costs. If only the material and laboratory costs are higher than the amount estimated in the cost estimate, the patient will have to tolerate this, provided that only an estimated amount was mentioned in the treatment and cost plan. The situation is different if the dental technology laboratory itself has submitted a cost estimate, and accordingly it is not an estimate.

The OLG Cologne differentiates here, however, whether the dentures are manufactured in a third-party laboratory or in a laboratory belonging to the practice. In their verdict of June 16, 1997, the judges reduced the invoice for dental services by 30 percent to the amount specified in the treatment and cost plan, although the HKP contained a note that laboratory costs can only be estimated. This notice was not accepted by the court because it was not clear why a dentist, especially one who has his own laboratory, should not be able to determine the expected laboratory costs to some extent exactly in advance (OLG Cologne, judgment from 16.06.1997, Az. 5 U 35/97).

If there is a discrepancy, seek the conversation

With regard to the dentist’s fee, the cost estimate is initially to be regarded as binding (see above). If there are major deviations between the cost estimate and the final invoice, it is advisable to first consult the dentist. Perhaps there is a billing error and the invoice has to be corrected. The higher fees can also be justified. This is the case if the dentist can justify the fee deviation in a way that is understandable for the patient, for example because an unforeseeable complication required an extension of the treatment, or because there were foreseeable difficulties, which the patient was advised of before the start of treatment. Reasons that are already known before the start of treatment, such as "exceptionally high salivation" or "severely restricted mouth opening" must already be taken into account in the cost estimate and do not usually entitle to subsequent increases in fees. If there is a subsequent increase, this is only possible up to 3.5 times the fee, because for higher rates a written declaration of consent from the patient is required (Section 2 (2) GOZ).

If the alleged discrepancies cannot be clarified, the patient can contact the responsible dental association or obtain information from a patient advice center. However, since this takes more time and often the invoice falls due within this time, a delay in payment should be obtained in practice. However, the practice does not have to grant a postponement and can continue to insist on payment of the complete invoice (§ 614 BGB) – provided the invoice was created in accordance with the requirements of the GOZ (§ 10 GOZ).

Conclusion: Ultimate security over costs is hardly possible

The explanations clearly show that a final estimate does not bring the patient certainty with regard to the expected costs. Because the amount of the later calculation depends on many factors, not all of which always appear in the treatment and cost plan. In the case of dentures, the material and laboratory costs in particular can vary. Even a higher consumption of precious metal quickly leads to a much higher invoice amount. And unforeseen difficulties during treatment can quickly lead to an increase in the increase factor in private treatments. After all, the range extends from one to 3.5 times the rate scale. With prior written agreement with the patient, even higher increases are possible. In any case, a patient is well advised if he requests a cost estimate for treatments that require a financial contribution, for which the dentist can charge a fee in accordance with the fee schedule for dentists for purely private treatments.

Before treatment
  • Have a detailed medical plan and cost plan (cost estimate) issued.
  • Have the cost estimate explained in detail.
  • Confirm that all required and foreseeable items (e.g. pre-treatment for dentures, accompanying services for prosthetic work) are included in the cost estimate.
  • If the increase factor is not evident in the estimate, ask for the increase factor.
  • Inquire whether expected difficulties have already been taken into account in the increase factor. Be careful when planning consistently with a factor of 2.3, as this rarely happens in reality.
  • At least for larger dental prosthesis treatments, request your own estimate from the dental technology laboratory.
  • Submit a quote to health insurance for review.
  • If necessary, obtain a second estimate.
  • Do not start treatment until the cost issue has been clarified.
After treatment
  • Verification of the final settlement with regard to the compliance with the treatment and cost plan (GOZ positions, increase factor).
  • If there is a discrepancy, speak to practice. If necessary, present an invoice to check a patient advice center or the responsible dental association.

Pallandt, Civil Code (BGB), C.H. Beck 2008
Liebold / Raff / Wissing, DER comment BEMA + GOZ, Asgard-Verlag 2009
Ries / Schnieder / Althaus, dentist law, Springer publishing house 2008
Oehler, Dental Standard in Jurisprudence, Deutscher Zahnärzte Verlag 2003
Oehler, The Dental Expert, Deutscher Zahnärzte Verlag 2004
Bavarian Chamber of Dentists, GOZ primer, BLZK 2005. (full text).
Current accounting, issue 03/2008
FVDZ, Practical Guide, 11/2009

This contribution was made by the in the imprint under "editorial staff" named dentists and dental specialists and didactically revised by the final editorial team.
Creation date: Jan 28, 2010, last change: Jan 28, 2010, last review: Jan 28, 2010.

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Christina Cherry
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