Definition and Introduction of the Uniform Value Scale (EBM)
The Uniform Value Scale (EBM) is a comprehensive billing system in the German healthcare sector. It governs the legal valuation and billing of medical and psychotherapeutic services provided by panel physicians and panel psychotherapists within the framework of statutory health insurance (GKV). The primary purpose of the EBM is to ensure nationwide, uniform, and transparent compensation for outpatient medical services.
Legal Foundations
Social Code Book
The legal foundation of the Uniform Value Scale is found in particular in the Fifth Book of the Social Code (SGB V). According to § 87 (1) SGB V, the EBM is determined by the Evaluation Committee, which is composed equally of representatives from the National Association of Statutory Health Insurance Physicians (KBV) and the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband). The Federal Ministry of Health and the Federal Social Security Office supervise compliance with the legal requirements within their respective jurisdictions.
Evaluation Committee and EBM Amendment Procedure
The Evaluation Committee is legally required to regularly adapt the EBM to the current state of science and technology as well as to economic conditions (§ 87 (3a) SGB V). Changes to the EBM are made by resolutions published in the Federal Gazette. In certain cases, the Federal Ministry of Health can issue amendment instructions.
Structure and Organization of the EBM
The EBM is divided into various sections, each covering different service areas. Every medical or psychotherapeutic service is assigned a fee schedule item (GOP), which defines specific service content, billing regulations, and points. The points indicate the relative value and effort of a service compared to others.
Point Values and Compensation
The equivalent value of a point, known as the orientation point value, is also determined annually by committees at the federal level (§ 87 (2) SGB V). The remuneration for a service is therefore calculated by multiplying the assigned point value by the current point value. Regional remuneration distribution rules, known as remuneration distribution scales (HVM), can influence the actual amounts paid out.
Function and Significance of the EBM in the Healthcare System
Regulation of Service Remuneration
The EBM serves as a central instrument for the uniform remuneration of billable medical and psychotherapeutic services in outpatient care. Through its detailed regulations, the EBM ensures transparency and reliability for service providers and payers.
Quality Assurance and Cost-Effectiveness
The continuous updating of the EBM contributes to quality assurance and cost-effectiveness in the healthcare system. Service descriptions and assessment criteria are in accordance with current medical guidelines and requirements for cost-effectiveness (§ 12 SGB V).
Distinction from Other Remuneration Systems
Unlike the Medical Fee Schedule (GOÄ), which applies to privately insured patients, the EBM is exclusively valid for the outpatient treatment of persons insured under statutory health insurance. The EBM billing system is strictly separated from purely private billing regulations.
Panel Physicians’ Remuneration and Impact on Healthcare Provision
Outpatient Medical Care under Statutory Health Insurance
The contractual relationships between panel physicians and health insurance funds, including billing and remuneration, are based on the provisions of SGB V and the billing modalities defined by the EBM. Compliance with the EBM thus ensures the legally compliant billing of medical and psychotherapeutic services.
Cost-Effectiveness and Plausibility Audits
Services billed according to the EBM are regularly subject to cost-effectiveness and plausibility audits by the Associations of Statutory Health Insurance Physicians and statutory health funds. These audit procedures serve to ensure the proper provision and billing of services (§ 106 SGB V).
Reforms, Further Development, and Criticism
Ongoing Adjustment
The EBM is subject to constant changes and further developments to reflect medical advances and new healthcare structures. These adjustments are necessary to keep outpatient care up to date and to ensure needs-based remuneration.
Points of Criticism
Criticism of the EBM primarily focuses on the complexity of the system, the valuation level of individual services, and the transparency of the amendment process. The influence of budgeting and regional remuneration distribution rules on the actual remuneration situation is also regularly discussed.
References and Sources
- Social Code Book (SGB V) §§ 87, 106
- Uniform Value Scale (EBM) – current version, National Association of Statutory Health Insurance Physicians (KBV)
- Federal Ministry of Health – Guidelines and Information on the Evaluation Committee
The Uniform Value Scale (EBM) is a central, legally binding set of rules for the remuneration of contractually agreed medical and psychotherapeutic services in Germany. Through its comprehensive codification, direct legal binding effect, and continuous further development, the EBM ensures statutory billing and ongoing adaptation to medical progress.
Frequently Asked Questions
How is the Uniform Value Scale (EBM) legally defined and what are the key legal foundations?
The legal basis for the Uniform Value Scale (EBM) is essentially found in the Fifth Book of the Social Code (SGB V), in particular in §§ 87 et seq. SGB V. It states that the Evaluation Committee according to § 87 (1) SGB V is tasked with creating and updating the EBM. Representatives from the National Association of Statutory Health Insurance Physicians (KBV) and the GKV-Spitzenverband are involved. The statutory regulation specifies the prerequisites, the systematics of service evaluation, and the procedure for updating the value scale. In addition, the provisions of the Social Code are decisive, particularly regarding participatory committees, transparency requirements, and the challenge of decisions made by the Evaluation Committee. Administrative regulations and practices within the Associations of Statutory Health Insurance Physicians also influence the legal design, as long as they are consistent with higher-ranking law.
What legal avenues are available for challenging EBM resolutions?
Resolutions of the Evaluation Committee regarding the EBM are subject to judicial review. Affected parties—typically the National Association of Statutory Health Insurance Physicians or the GKV-Spitzenverband—have the opportunity to initiate an arbitration process under § 87 (6) SGB V against resolutions of the Evaluation Committee. In addition, a lawsuit can be filed before the Higher Social Court, which, through a judicial review, examines whether the resolution complies with higher-ranking law. Furthermore, individual physicians or Associations of Statutory Health Insurance Physicians, if they assert that the application of the EBM infringes their rights, may, after exhausting administrative procedures, bring action before the Social Courts. Decisive here is always the assertion of a legal violation or challenging the legality of the EBM decision.
To what extent does the EBM influence the remuneration of contract medical service providers in accordance with legal requirements?
The EBM is a central instrument for the statutorily regulated remuneration of contractual medical services. Its legal effect results from the fact that it serves as a binding standard for the evaluation and billing of medical and psychotherapeutic services within the framework of statutory health insurance (§ 87 SGB V). The valuations (point values) included in the EBM and their conversion into euro amounts are based on the legally agreed total compensation between the Associations of Statutory Health Insurance Physicians and health insurance funds. Violations of the EBM or non-compliance in billing may result in recourse claims or disciplinary actions under § 106 SGB V, as the EBM is part of the statutory framework for contractual medical activity.
Who is legally required to apply the EBM and what are the consequences of a violation?
All contract physicians, contract psychotherapists, and MVZs who participate in outpatient care in accordance with §§ 95, 95a, 311 SGB V are legally obliged to apply the EBM. Compliance is monitored by the Associations of Statutory Health Insurance Physicians. A violation of the rule-compliant billing under the EBM is considered a breach of SGB V and the physician’s obligations under the admission contract, and can lead to disciplinary actions, reductions in remuneration, claims for repayment, and, in severe cases, professional legal consequences (up to withdrawal of approval).
Is there a legal obligation for regular review and updating of the EBM?
Yes, the ongoing updating and adjustment of the EBM is a statutory duty of the Evaluation Committee according to § 87 (2) SGB V. Changes in medical science, healthcare practice, or the remuneration system must be regularly and promptly implemented in the EBM. Failure to update could constitute a violation of the requirement for economic, appropriate, and needs-based care under § 12 SGB V and thus be legally contestable.
To what extent are the provisions of the EBM binding for privately insured persons?
Legally, the EBM applies exclusively to outpatient care within the framework of statutory health insurance and is therefore generally not applicable to the treatment of privately insured patients. Billing for privately insured persons is normally based on the Medical Fee Schedule for Physicians (GOÄ). However, in rare cases, the EBM may be used as a reference for private remuneration, for example, in court disputes over the appropriateness of private charges; though this is not binding.
What special protective mechanisms for physicians does the law provide in the context of EBM amendments?
When making changes to the EBM, right to a hearing and transparency requirements must be especially observed. According to § 87 SGB V, the Evaluation Committee is obliged to comprehensively inform and hear the affected groups, particularly professional associations and representatives of specialties, before fundamental changes are made. Moreover, every amendment must be published in the Federal Gazette, providing legal certainty for all parties involved and enhancing transparency in the legislative process. Physicians also enjoy a certain level of legitimate expectation regarding reductions in remuneration, especially for services already performed, as long as billing was not unlawful.
