For HospitalsRecord-based billing

An unbilled record is a claim that does not exist yet.

Under § 12 (1) of the German medical fee schedule, payment only falls due once a compliant invoice has been issued. Until then the stay sits in the record rather than in the books. We structure the record far enough that every billed item carries its source passage, check reductions, exclusions and multipliers through fixed rules, and hand the result to whoever does your billing — in-house or at your service provider.

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Why the stack grows

When billing runs off a service sheet, somebody decided in advance what would be charged. Record-based billing has no such sheet: the admission findings, the operation report, the anaesthesia protocol, the progress notes, the consultations and the discharge letter are all there, and the billable items have to be reconstructed from them. It is the most labour-intensive form of billing and the first thing to slip when the billing office is short-staffed. In some hospitals the result stands in the room as a stack of paper, and the stays inside it are a year old or more. For the physicians who share in the pool, that is fee income nobody has claimed yet.

German medical fee schedule (GOÄ), § 12 — when payment falls due

§ 12 (1)Payment falls due only once the payer has been issued an invoice that complies with the fee schedule. Before that there is no due claim.GOÄ § 12 (1)

3 yearsThe standard limitation period under § 195 of the Civil Code. On the Federal Medical Association's reading it starts at the end of the year in which a compliant invoice was issued.§ 195 BGB; Federal Medical Association, fee-schedule guidance

ForfeitureSeparately from the limitation period, a fee claim can be forfeited where the invoice goes unwritten for a long time. The Federal Medical Association therefore advises billing quarterly.Federal Medical Association, limitation and forfeiture

2.3×Above this multiplier, exceeding it must be justified in writing, per individual service, comprehensibly and traceably for the payer.GOÄ § 12 (3), § 5 (2)

The work is not in entering the fee numbers. It is in the question every invoice review asks: where in this record does it say that? A justification under § 12 (3) asserts a fact about the treatment, and where that fact is not documented, the justification does not hold. In record-based billing the invoice and its justification are therefore produced in the same step. That is what makes it slow, and it is the point at which something can change.

GOÄ § 5 (2) sentence 4 — the standard range and exceeding 2.3×

How the invoice is produced

Five steps. The third is deliberately not a language model.

The record becomes readable

Scans, dictations, forms and printouts are taken in, assigned to document types and put in order: admission, operation, anaesthesia, progress, consultation, discharge. Before that the record is a stack; after it, a case.

Every item carries its source

Each proposed item comes with what it follows from: document, page, passage, date of documentation and the person who documented it. No similarity value, no probability. Where no source passage exists, the item does not appear as a proposal but as a documentation gap, naming the document the evidence would have to sit in.

Fee law runs on fixed rules

Exclusion relationships, timing conditions, frequency limits, the inpatient reduction and the ceilings on multipliers are rules with a defined answer. Whether one fee number may be billed alongside another is not a matter of judgement. That check is deterministic rather than a language model, because a model that applies an exclusion rule mostly correctly leaves the error invisible until it is challenged.

Justifications are built only from what is documented

The justification required under § 12 (3) is assembled from facts that are in the record, and from no others. Where the documentation is silent, no justification is produced. That yields a shorter draft invoice and a more complete evidential position.

Only a person can release it

Without confirmation by an authorised person no item comes into being. Who confirmed what, when, and what they changed remains traceable. A system that supplies proposals but does not record how a proposal became an invoice merely moves the evidence problem from coding into approval.

That settles the division of labour: language processing to understand the documentation, a rule engine to apply fee law. Solving both in the same place would be more convenient and more expensive under review.

What happens to the gaps

An item that cannot be evidenced is rarely a billing problem. It is usually a documentation problem, and it belongs back where it arose — in the language of documentation rather than the language of billing. So: the daily specialist ward round is not documented for treatment days six and seven, rather than: a fee number is unsupported.

A review after the fact redistributes revenue. Feedback that arrives while the case is still open changes the documentation of the next case. That is what the process aims at.

Every finding is stored in a structured form: item, type of objection, department, missing document type. Over a period that answers questions a single case cannot — which document type causes the most objections, whether a training session moved a department's rate or merely took place, and which items are struck regularly. Rates are reported with their denominator. That 340 items were objected to in one month means nothing without one.

Handing over to billing

We do not issue invoices. What comes out at the end is a checked, evidenced and released data set, and it goes wherever billing happens in your hospital.

To your own private-billing office, as a structured export in the order and fields that system expects
To your billing service provider. Connections to some already exist; with others we set the handover up once format and route are settled. Changing provider is not a precondition.
To chief-physician billing with the inpatient reduction itemised, which the fee schedule requires on the invoice in any case
With the processing history, so that in a dispute it stays traceable what an item rested on and who released it

Responsibility for the invoice stays with the hospital, or with the physician entitled to bill. We transmit nothing to insurers or patients.

What the fee-schedule reform changes

The reform of the German medical fee schedule has been agreed between the Federal Medical Association and the private insurers' association, published in draft, and endorsed by the 129th German Medical Assembly. It has not been adopted, and no date of entry into force is fixed. Anyone deciding on billing processes today should still know the draft.

Three points bear directly on record-based billing. The fee catalogue grows to around 5,500 items including surcharges, on the Federal Medical Association's own figures. The invoice is to carry the official diagnosis and procedure codes and to exist in a machine-readable format. And the inpatient reduction stays, and still has to be itemised on the invoice.

A process that already codes out of the record and ties every item to a source passage carries those changes more easily than one waiting for a completed service sheet. That is an argument for rebuilding, not a reason to hurry: while nothing is adopted, we name no date.

Federal Medical Association, information on the fee-schedule reform

What the module explicitly does not do

It does not bill on its own. Every item is confirmed by an authorised person before invoicing; without that confirmation no item comes into being.

It asserts nothing that is not in the record. Justification text is built exclusively from evidenced facts. Where the documentation is silent, a gap notice is produced rather than a sentence.

It makes no diagnoses and proposes no treatment. What it contributes to coding is called a coding proposal and treated as one. No assessment of patients takes place.

It transmits nothing. Nothing goes to insurers, patients or a billing office without the hospital's release; in the statutory data-exchange area we prepare and check the data, and transmission stays with the hospital information system.

None of the modules described here falls under Rule 11 of the EU Medical Device Regulation. We structure, check and evidence documentation. The regulatory qualification is documented before any function is developed; where a planned function departs from it, it is re-qualified before it is built.

What runs today, what follows

Where each part currently stands. This overview is kept up to date.

In use

Making records readable

Bulk upload of whole document sets, assignment to document types, a timeline across the case, the source shown beside every adopted entry. Shipped and in operation.

In trial

The fee-schedule pipeline

Coding out of the record, a source passage per item, deterministic rule checking for exclusions and reductions, justifications from evidenced facts, and a three-tier assessment of each proposal. The architecture is assessed and it is being trialled at one partner hospital together with a billing service provider. No hospital is billing through it productively yet.

Planned

Feedback and analysis

Gap notices sent back to documentation while the case is still open, structured storage of the findings, and the monthly analysis by department, objection type and missing document type.

Watched

The reform

Around 5,500 items, official diagnosis and procedure codes on the invoice, a machine-readable invoice format. We follow the draft and build the pipeline so that it can absorb it. We will name an implementation date when there is one.

Legal framework and data processing

Processing entirely within the European Union (data centre in Frankfurt); no additional sub-processors inside the professional-confidentiality circle under § 203 of the Criminal Code.
Information security to ISO/IEC 27001, certified by TÜV Nord. The German cloud-security catalogue at type 2 level is in preparation for our own operation; we do not rely on the data-centre operator's attestation for it.
Quality management system aligned to the principles of ISO 13485, with the regulatory qualification documented before any function is developed.
Rulebooks accounted for: the medical fee schedule (in particular §§ 5, 6a, 12), § 17 of the Hospital Remuneration Act for optional services, §§ 195 and 199 of the Civil Code on limitation, and § 301 Book Five of the Social Code for data exchange with statutory payers.
Templates for the data processing agreement and the data protection impact assessment are part of the delivery; a works council information pack is available.
Preparation for the requirements of the EU AI Act. AI-supported proposals and draft text are labelled, and AI literacy training for hospital staff is part of the delivery.

Frequent questions

We have a billing service provider. Are you competing with them?

No. They bill; we prepare. The laborious part sits upstream of billing: getting the billable items, with their source passages, out of an unstructured record. What happens afterwards — invoicing, dunning, disputes — stays where it is today. Connections to some providers already exist; with others we set the handover up.

How old can the records be that we have worked up?

Technically the age does not matter. Legally it does: the standard limitation period is three years, and separately a claim can be forfeited where the invoice has gone unwritten for a long time. How a particular stack stands belongs with your legal advisers; we supply the basis for that assessment, not the assessment.

Who is liable for an item that is challenged later?

The physician entitled to bill, or the hospital. No tool changes that, which is why release by an authorised person is mandatory. What we supply is the basis for that decision: the source passage for every item, and the notice where one is missing.

Why do you also name items we should strike?

Because over a review period they cost more than they bring in. A struck item costs revenue once. A challenged item costs revenue, handling time in the dispute, and on repetition the negotiating position. Proposals are therefore graded in three tiers: evidenced, contestable with the expected objection named, or untenable.

Do you point a language model at fee law?

At understanding the documentation, yes. At applying the rules, no. Exclusion relationships, frequency limits and the inpatient reduction have a defined answer, so they run on fixed rules. A model that applies such rules mostly correctly is the wrong tool here, because the error only surfaces when it is challenged.

What happens to our data?

It is processed in Frankfurt and does not leave the European Union. The professional-confidentiality circle is not widened by further sub-processors. Templates for the data processing agreement and the data protection impact assessment are part of the delivery.

Should we wait for the new fee schedule?

The reform is agreed and published in draft, but not adopted, and no date is fixed. A stack that is sitting there today will not get any younger for it. The draft argues for converting sooner: a process that codes out of the record and evidences every item absorbs a larger catalogue and a machine-readable invoice more easily.

How do we start?

With completed cases from your own hospital where there was a challenge. They show what a proof of origin does and what it does not — including if you end up staying with your current process.

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A look at your stack

We take a handful of completed cases, ideally ones that were challenged, and show which items can be evidenced, which are documentation gaps, and where the time goes today. If no argument comes out of it, we say so.

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