Pharmacists can reclaim amounts that have been wrongly adjusted from 2024 onwards. Those who cite the case law of the highest court in this regard usually encounter little resistance from health insurance funds.
The situation is different for a second, often overlooked item: the health insurance discount. If health insurance funds reduce their payment by offsetting it against a subsequent collective invoice, they routinely retain the health insurance discount applicable to that invoice in accordance with Section 130 of the German Social Code, Book V (SGB V).
The health insurance deduction is not a separate claim for reimbursement by the health insurance funds, but a kind of discount: health insurance funds only receive it if they settle the pharmacy’s invoice in full within ten days. In the absence of a valid counter-claim for a retax, the set-off comes to nothing – the payment then effectively amounts to a mere partial payment, which, according to the established case law of the Federal Social Court, does not justify the discount.
As health insurance funds generally do not disclose which specific individual invoice they have used for the set-off, pharmacies have no choice but to rely on the relevant collective invoice as a whole – with the consequence that the health insurance fund discount must then also be fully reimbursable. It is the responsibility of the health insurance funds to ensure transparency. Any failure to do so must not be at the expense of the pharmacies.
A final clarification will only come with a further ruling by the Supreme Court in Kassel. Until then,Dr Fiete Kalscheuer and Dr Johannes Fitzke,solicitors specialising in pharmacy law, recommend that pharmacists actively claim back the health insurance deduction when reclaiming amounts from unjustified retaxations.