Power of attorney for a doctor indicating extraordinary reimbursement of treatment according to § 16

Since the beginning of 2022, an amendment to the Public Health Insurance Act has been in force concerning extraordinary reimbursements according to Section 16.In this context, insurance companies have started to require a power of attorney from treating physicians, who often submit claims on behalf of patients. Why is this so? You will find an explanation in this article, together with a sample power of attorney.

Recall that Section 16 applies in exceptional cases where the patient's treatment is not covered by the public health insurance system and where the provision of such health services is the only option in view of the patient's medical condition.

The amendment to the Public Health Insurance Act established a procedure whereby a request for extraordinary reimbursement can be submitted by a health care provider or a patient. If the request is granted, there is no problem. However, if the request is not granted, the health insurer issues an administrative decision. The decision can be appealed within 15 days in accordance with the procedure to which the Administrative Code applies. This is where the problem arises. The party to the administrative procedure is no longer the health service provider, but only the patient. Therefore, if the attending doctor wishes to continue to act on behalf of the patient in the proceedings, and in particular to lodge a timely and reasoned appeal on the patient's behalf, he or the health service provider under which he operates must be duly authorised to do so. Hence the requirement for the health insurer to provide evidence of a power of attorney.

While it is commonplace for us attorneys to create a power of attorney, and it is on that basis that we also represent patients in filing a request for extraordinary reimbursement or in resolving an appeal, physicians may not be sure of the kinks in creating one. Therefore, we have created a model power of attorney for physicians' use and make it freely available. After all, we work closely with physicians in handling each Section 16 case, and we want to help them with the paperwork so they can get on with their work.

The model provides for two proxy variants. Depending on the treating physician's preference, either the treating physician as an individual or the health care provider under which he or she operates may be designated as the agent. A legal entity may also be a proxy under the Administrative Order.

Whether the treating physician or the provider is designated as the agent, it is good to know that the agent's actions will create rights and obligations directly for the patient, only the agent will be served, and only one agent can be named in the matter.

In practice, the need for a power of attorney should only arise for a physician in the context of an appeal, as the request itself can be made by the provider. Unfortunately, the 15-day period often proves to be very short in practice and the doctor does not always manage to contact the patient within this time. It may therefore be useful to equip the doctor or provider with a power of attorney in advance so that they can use it quickly in the event of a negative administrative decision.

Still not sure how to handle the health insurance company's request? Are you dealing with a complicated dispute over extraordinary reimbursement? Contact us.

PM_§16_KD.docx