Key points for cooperation between fitness studios and health insurance companies in the context of prevention courses
Fitness studios and health insurance companies - a relationship that has often been characterized by mutual misunderstandings in recent years. On the one hand, many fitness studios did not understand what and in what form cooperation with health insurance companies could be realized. On the other hand, some local employees of health insurance companies did not always know how to implement what the respective head offices had already decided.
However, the biggest misunderstanding still seems to exist in the question of the implementation of prevention and health courses within the meaning of §20 SGB V - to the point of misuse of this legal possibility.
The following article will therefore first present and comment on the current key points of Section 20 SGB V. Properly understood, this field offers an extremely interesting opportunity for health-oriented fitness studios, which will be discussed in conclusion.
Requirements of Section 20 SGB V
The key "take home messages" are presented here in brief.
■ Section 20 SGB V relates to prevention courses in groups (usually groups of 10-12, max. up to 15 participants).
■ In addition to the topics of nutrition, relaxation and substance abuse, the courses can also be offered on the topic of exercise habits (so-called "fields of action").
■ A prevention course is offered by a so-called course provider (i.e. a qualified trainer) ("provider").
■ The course can also be held in the (course) rooms of fitness studios - the studio merely provides the room; it is basically only an "intermediary".
■ The course fee is paid in advance by the participants to the provider.
■ After the course, participants can apply to their health insurance provider for reimbursement of the fee (usually 75% of the course fee).
■ The prerequisite for reimbursement by the health insurance provider to its policyholders is that both the course and the instructor are recognized by the health insurance provider.
■ In order to be recognized, the requirements of Section 20 SGB V, which are specifically set out in the criteria of the GKV Prevention Guidelines, must be met.
■ Since 2014, recognition has been granted by the Central Prevention Testing Centre.
Legal basis
The regulations in the German Social Code (here §20 SGB V) are relevant for the health insurance funds when it comes to the recognition of prevention courses - including the GKV Prevention Guidelines (adopted for the implementation of §20 SGB V) as amended.
Claim of §20 SGB V
The following passage can be found in §20 SGB V:
"§20 SGB V Prevention and self-help
(1) The health insurance fund should provide for primary prevention benefits in its statutes that meet the requirements set out in sentences 2 and 3. Primary prevention benefits should improve the general state of health and in particular contribute to reducing socially induced inequalities in health opportunities. The National Association of Statutory Health Insurance Funds shall jointly and uniformly decide on priority fields of action and criteria for services in accordance with sentence 1, in particular with regard to need, target groups, access routes, content and methodology, with the involvement of independent experts.
(2) The expenditure of the health insurance funds for the performance of their tasks in accordance with paragraph 1 and §§ 20a and 20b shall amount to a total of EUR 2.74 for each of their insured persons in 2006; it shall be adjusted in subsequent years in accordance with the percentage change in the monthly reference value in accordance with § 18 paragraph 1 of the Fourth Book.
(3) and (4) (omitted)"
Section 20 therefore only mentions the global objective of " ... improving the general state of health ..." - with special consideration given to reducing social inequality. This in turn can be achieved via various "access routes", either in the so-called "setting" or "living environment" (e.g. daycare center, school, company) or in the "individual approach"
(e.g. exercise classes).
For fitness studios, the "classic prevention courses" are certainly the first option. These prevention courses are aimed at the individual insured persons (individual approach) and are intended to enable and motivate them to behave in a health-promoting manner, e.g. to exercise more.
Some gyms may also be interested in establishing themselves as providers in the setting sector. Companies that are particularly interested are often mentioned here
(§20a SGB V). However, in order to be taken seriously there, the studio should first have acquired the relevant expertise under the keyword BGM or BGF (occupational health management or health promotion). This approach may then also be feasible.
GKV guidelines on prevention
In order to implement the overall objective of "improving the state of health", the National Association of Statutory Health Insurance Funds, together with independent experts, had to define so-called "fields of action" and also the "criteria for services". These define which services can be provided and recognized and reimbursed by the health insurance funds within the meaning of this §20.
This was done years ago, has been repeatedly revised and can be read in detail in the current version of the so-called "GKV Guidelines on Prevention". The best place to find this important information is under the keyword GKV, as the "GKV-Spitzenverband" is the "Spitzenverband Bund der Krankenkassen" in accordance with §217a SGB V.
The GKV prevention guidelines are decisive for the implementation of prevention courses in accordance with §20 SGB V. In it, the National Association of Statutory Health Insurance Funds (GKV-Spitzenverband), in cooperation with the associations of health insurance funds at federal level, defines the so-called content-related fields of action and qualitative criteria for the services of the health insurance funds within the meaning of §§20 and 20a SGB V, which are binding for the provision of services on site.
Knowledge of the guidelines and compliance with their rules is therefore essential if a course provider wishes to have themselves and/or a prevention course recognized by the health insurance funds.
Measures that do not comply with the principles set out in these guidelines may not be carried out or funded by the health insurance funds within the framework of §20 and §20a SGB V. In the area of fitness studios, this primarily concerns individual training or training exclusively or predominantly on stationary fitness equipment.
Fields of action in prevention
But what are fields of action? Fields of action" refers to the areas of life for which prevention courses are offered.
For primary prevention in the individual approach according to §20 Para. 1 SGB V, these fields of action are as follows
■ Exercise habits,
■ Nutrition,
■ Stress management and
■ Addictive substance use.
Similar, but more company-specific fields of action are listed for workplace health promotion (Section 20a (1) SGB V):
■ Work-related physical strain,
■ Company catering,
■ Psychosocial strain (stress) and
■ Addictive substance use.
Even if all areas can in principle be relevant in the area of fitness studios, the main focus is generally on the area of activity habits, so that the following explanations also concentrate on this.
Physical activity habits field of action
Offers in the physical activity habits field of action are aimed at
a) the reduction of physical inactivity through health-related sporting activity and
b) the prevention and reduction of specific health risks through suitable behavioral and health-oriented exercise programs.
These two objectives are also referred to as the "prevention principle". While principle a) is very unspecific, principle b) explicitly addresses risks. Therefore, the courses offered are also more specific, and more specific requirements apply to the course instructors.
Who is a "provider"?
In principle, providers (i.e. course instructors) with the following qualifications are eligible to carry out the measures - always taking into account the explanations of the individual prevention principles.
■ Basic qualification: State-recognised professional or academic qualification in the relevant field (field of action)
■ Additional qualification: Specific further training recognized in the professional world
■ Instruction in the programme to be carried out
(may be included in the additional qualification).
■ Furthermore, providers must have pedagogical, methodological and didactic skills as well as professional experience.
According to the GKV guidelines for prevention principle a), the following applies in the field of physical activity habits:
"Professionals with a state-recognized professional qualification or degree in the field of physical activity are eligible to implement appropriate measures, in particular
■ Sports scientists (degrees: Diplom, state examination, Magister, Master's, Bachelor's)
■ Physiotherapists
■ Sports and gymnastics teachers
■ Doctors,
provided that they have been specially instructed in the health sports program to be carried out as part of a training course."
In addition, contrary to the above-mentioned principles, specially trained DOSB exercise instructors who are active in special courses are also permitted as providers. (Incidentally, in the future, it will also be a concern of the professional fitness associations to achieve this recognition for those specially trained in the fitness sector).
In the case of prevention principle b), further requirements must also be met, in particular proof of additional qualification from a recognized institution for the respective problem area (e.g. back trainer license; comparable in other indication areas) and instruction in the exercise programme to be carried out.
Testing and approval of providers and courses
Since the beginning of 2014, the "Central Prevention Testing Center" has decided on the approval of all offers (on exercise habits). This body examines and certifies the prevention courses in accordance with Section 20 (1) SGB V and awards the "German Standard for Prevention" seal of approval if the examination is successful.
According to the website, the examination takes place "and within 10 days".
Billing modalities
Only those who organize their courses in accordance with these guidelines have a chance of being recognized and reimbursed by the health insurance companies.
It is important to mention here that it is not the studio or the course instructor who receives the reimbursement, but that the services of the health insurance companies are directed towards the individual insured person, in the sense of reimbursement of previously paid course fees. This reimbursement usually amounts to 75% of the respective course fee.
The prerequisite for this is that the insured person has attended at least 80% of the course hours. If courses within the meaning of §20 SGB V are offered, participants pay the agreed fee in advance (e.g. 100 euros for ten teaching units) and receive a refund of three quarters of the fee after the end of the course on presentation of the course instructor's certificate of successful participation to their health insurance provider.
Incidentally, health insurance companies only support temporary measures and usually only two different (!) areas of activity ("courses") per year, or the same area of activity only every two years.
Outlook
In order to benefit from the reimbursement system for prevention courses, prior recognition of the course offer and the provider - currently via the Central Prevention Testing Center - is required. And quite strict rules apply here with regard to criteria such as process, structural and outcome quality.
As experience has shown that individual trainers (providers) find it extremely difficult to cope with the extensive application process, the next issues of F&G will explain ways in which existing offers and aids for application and billing can be used. At the same time, it will be discussed how fitness studios can position themselves in this system and participate in it.
Prof. Dr. Theodor Stemper
§20 SGB V
Download the Social Code, §20 SGB V
http://www.sozialgesetzbuch-sgb.de/sgbv/20.html
GKV Prevention Guidelines
Download the GKV Guidelines
http://www.gkv-spitzenverband.de/media/dokumente/presse/publikationen/GKV_Leitfaden_Praevention_RZ_web4_2011_15702.pdf
Central Prevention Testing Center
Download the Central Prevention Testing Center
http://www.zentrale-pruefstelle-praevention.de/admin/
Source: F&G
Images: rcx - fotolia.com
Published on: 12 September 2014