LSG Hamburg: Clinic receives only a flat rate if it is re-admitted
(jur). If a patient has to go to the hospital a short time later after an operation due to complications, the clinic cannot fundamentally bill the procedures individually. This also applies if the patient has left the clinic prematurely against medical advice, but the later complications cannot be attributed to it unquestionably, the State Social Court (LSG) Hamburg decided in a judgment published on Tuesday, September 6, 2016 (Az. : L 1 KR 116/13). Because of its fundamental importance, the appeal to the Federal Social Court (BSG) in Kassel was permitted.
In the specific case, it was about the settlement of inpatient hospital treatment of a toddler. In the child admitted on July 2, 2008, a blood sponge was surgically removed on the back the following day. The procedure itself went well, but shortly afterwards a pressure bandage had to be applied due to heavy bleeding.
The doctors advised the mother to keep the child in the clinic until July 7, 2008. But contrary to medical advice, the mother took the child home two days earlier. In the discharge certificate, the doctors noted the following risks: "wound infection, bleeding, bleeding resulting in death".
On July 16, the child had to be hospitalized again because the wound opened again and had to be treated with surgery.
For the first treatment, the hospital asked the health insurance company to pay 2,458 euros, and for the second stay she billed an additional 1,759 euros.
The health insurance company paid first, but then demanded 1,653 euros back. The clinic received a lump sum for the treatment of the child, which included the treatment of later complications. The two hospital stays should therefore not be billed individually.
The complications only arose because the mother took her child with her against the medical advice two days earlier, the clinic subsequently argued. The mother had also missed the date for the reinstatement on July 7, 2008.
In its judgment of May 26, 2016, the LSG made it clear that a hospital can only receive a lump sum per case if they return to the hospital due to complications. The prerequisite for this is that the complication still occurs within an upper limit retention period defined for each illness. In the specific case, this was 15 days. The complications occurred within this time, so that the clinic could only claim a uniform remuneration.
The situation is different if the complications arise due to the unreasonable behavior of the insured or a third party. Here, however, there are doubts that the premature discharge caused by the mother is responsible for the second hospital stay, according to the LSG. There is also no clarity from the inadequate documentation on the admission report and at the pediatrician for the period between discharge and re-admission. "According to the case law of the BSG, the complaining hospital must fundamentally bear the risk that the cause of the wound healing disorder leading to the resumption cannot be identified. fle / mwo
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