GOÄ factors: what your documentation has to support

Outside sections A, E, M and O and no. 437, the GOÄ multiplier (Steigerungsfaktor) may lie between 1.0 and 3.5. Up to 2.3 no written justification is needed; above it, every single line needs one that is understandable and traceable for the person paying. More than 3.5 is only possible with a fee agreement signed before the treatment. Whether a factor holds is decided by the documentation.

How a GOÄ fee is calculated

Every service in the fee schedule has a point count. Points times the point value gives the simple fee; the point value is 5.82873 cents.¹ The multiplier scales that simple fee. It is the lever today's GOÄ uses to express that a single service was, in the specific case, more difficult, more time-consuming or performed under harder circumstances.

Take the detailed consultation, no. 3 (150 points, at least 10 minutes):²

For no. 3, the step from 2.3 to 3.5 is worth just over ten euros per line. Over a quarter with many long conversations, that is no rounding error.

Which ranges apply

The GOÄ distinguishes three groups, each with its own range and its own threshold. The threshold (Schwellenwert, the usual term) is the point up to which § 12(3) GOÄ requires no written justification.¹

So anyone who applies 2.3 and 3.5 to lab or radiology is already wrong at the threshold. For hospital services billed by a chosen doctor (Wahlarzt) and performed neither by that doctor nor by their permanent deputy named in advance, the caps drop to 2.3 and 1.8. Lower maximums also apply to patients in the private insurers' standard tariff (Standardtarif, § 5b GOÄ: 1.7; sections A, E, O 1.3; section M 1.1) and to the services listed in § 24b(4) SGB V for a termination of pregnancy under § 218a(1) StGB (§ 5a GOÄ: 1.8).¹

When the factor may exceed 2.3

The GOÄ names three criteria: the difficulty of the individual service, the time it took, and the circumstances in which it was performed. Within the fee range the doctor sets the factor "at reasonable discretion" on these criteria. As a rule it may only lie between 1.0 and 2.3; above that only when particular features of exactly these criteria justify it.¹

One sentence in § 5 is easy to miss: criteria that are already part of the service description do not count a second time.¹ No. 3 already requires at least 10 minutes. That a conversation lasted 10 minutes therefore cannot raise the factor. That it lasted 30 minutes, and why, can.

What the justification must say

When a fee exceeds the threshold, the bill must justify it in writing, "related to the individual service" and "understandable and traceable" for the person paying. On request, the justification has to be explained in more detail.¹ According to the guidance of the German Medical Association (Bundesärztekammer), this requires an individual justification related to the specific case. In its guidance, a bare reference to a "particularly time-consuming" or "particularly difficult" service is not enough.³ As early as 2005 it wrote that one blanket justification across a bill is "only rarely tenable".⁴

Each of the stronger justifications assumes the circumstance is in the documentation. A justification that exists only on the bill is a claim without evidence.

Above 3.5: the fee agreement

A fee higher than 3.5 is only possible through a separate agreement under § 2 GOÄ (Honorarvereinbarung). The rules are tight:⁵

• It is made case by case after a personal conversation, before the service is provided, and in writing.
• It states the number and name of the service, the multiplier and the agreed amount, plus a note that reimbursement may not be guaranteed in full. It may contain nothing else.
• Points and point value cannot be agreed differently, only the fee amount.
• It is not allowed for services in sections A, E, M and O or under § 5a; for inpatient Wahlarzt services only for services the Wahlarzt performs in person (höchstpersönlich), not through a deputy. Emergency and acute pain treatment may not be made dependent on it.
• The person paying receives a copy.

According to the Bundesärztekammer's guidance, having staff collect signatures on prepared agreement texts is not permissible; the individual entries such as service, multiplier and amount should be filled in by hand.³

Where practices lose, in both directions

Too low. When a complex, time-consuming service is billed at the routine factor although the documentation shows the extra effort, fee income is left on the table. The case was demanding, the documentation even shows it, but the bill says 2.3.

Too high. Factors above the threshold that the documentation does not support, or the same justification on every line. It surfaces at the latest when the person paying asks for an explanation, which § 12(3) GOÄ obliges the practice to give. According to the Bundesärztekammer's GOÄ guide, a blanket justification can even stop the fee from falling due.⁴

The safe position is the same in both cases: the factor the documentation supports.

What the documentation has to support

For a factor above the threshold to hold, the documentation of the contact should show:

• how long the service actually took, if time is the reason,
• what made the case harder than the average case, in the words of the case,
• which circumstances made performing it harder,
• and that it is something not already part of the service description.

If a billing office (Verrechnungsstelle) runs your GOÄ, the quality of what reaches it decides the outcome. meda works upstream: it writes the documentation from the consultation and shows the GOÄ services and factors it supports, each with the sentence that backs it. The doctor approves, then it flows into the process you already trust. Why this habit also counts under the future GOÄ is in our article on GOÄneu.