Die richtigen Argumente – 6 Tipps zum Umgang mit Krankenkassen und Behörden

05. Juli 2013 · Autor: HM · Druckversion Druckversion

Ämter, Behörden und Krankenkassen haben leider oft eine andere Auffassung als diejenigen, die sich dorthin wenden, wenn es z.B. um die Kostenübernahme für ein Hilfsmittel, für eine Rehamaßnhame, Krankengymnastik o.ä. geht, Pflegegeld gestrichen oder gekürzt, Zuschüsse für Umbauten abgelehnt werden oder es Auseinandersetzungen über den Hinzuverdienst zu Renten gibt. Die Liste lässt sich beliebig fortsetzen.

Abbildung: abgelehnter Antrag der Pflegekasse, Autor Kurt F. Domnik / pixelio.de

Betroffene, die nicht regelmäßig damit zu tun haben, machen dann gelegentlich den Fehler, nicht so zu argumentieren, wie es gerade für diese Behörde und dieses Gesetz erforderlich wäre, denn die jeweiligen rechtlichen Grundlagen sind völlig unterschiedlich, je nach dem ob es sich um eine Krankenkasse handelt, ein Sozialamt oder z.B. die Pflegeversicherung. Die Folge: Ein berechtigter Anspruch wird aufgegeben, weil man vor dem Papierkrieg resigniert, Frust baut sich auf und „denen da oben“ wird die Schuld zugewiesen.

Die folgenden sechs Tipps helfen die häufigsten Fehler im Umgang mit Krankenkassen und Behörden zu vermeiden:

Alle Anträge schriftlich einreichen
Grundsätzlich sollten alle Anfragen und Anträge, nicht nur für Hilfsmittel, schriftlich eingereicht werden (am besten auch eine Kopie anfertigen). So vermeidet man Missverständnisse weil z.B. ein Telefonat unterschiedlich interpretiert wurde oder weil sich der Gesprächspartner auf der anderen Seite an nichts mehr erinnern kann. So wird ein „Vorgang“ produziert.

Namen erfragen und notieren
Bei persönlichen oder telefonische Gesprächen die sich trotzdem ergeben: Namen erfragen und notieren. Bei wichtigen Dingen eine Gesprächsnotiz verfassen und eine Kopie als Bestätigung an Krankenkasse oder Behörde schicken.

Detaillierte Auskünfte nur an den MDK
Nur der MDK hat einen Anspruch auf detaillierte Auskünfte in Gesundheitsfragen (direkt oder auch vom behandelnden Arzt). Auch wenn von der Krankenkasse oft direkt nachgefragt wird gehen gesundheitliche Details z.B. wegen der Versorgung mit einem Hilfsmittel den oder die Sachbearbeiter bei der Krankenkasse nichts an, auch keine freiberufliche Berater, denen Sie nur Auskunft geben müssten, wenn Sie vorher schriftlich zugestimmt haben.

Wissen, wie die Verordnung begründet ist
Es ist wichtig zu wissen wie die Verordnung für ein Hilfsmittel begründet ist. Das erleichtert bei einer Ablehnung die Argumentation erheblich. Deshalb sollte man grundsätzlich eine Kopie anfertigen damit diese ggf. zur Hand ist. In Notfall kann das ja auch in der Arztpraxis erfolgen. Dort steht üblicherweise ein Kopiergerät.

Neue Fristen für Hilfsmittelanträge
Seit dem 26. Februar 2013 ist die Krankenkasse verpflichtet, über einen Hilfsmittelantrag innerhalb von drei Wochen zu entscheiden. Muss ein Gutachten hinzugezogen werden verlängert sich diese Frist auf 5 Wochen. Sollte die Frist nicht eingehalten werden können ist eine schriftliche Information mit Begründung erforderlich. Aber ein Hinweis nur auf Arbeitsüberlastung ist kein Argument. Nach Ablauf dieser Frist kann das Hilfsmittel selbst beschafft werden und es besteht ein Rechtsanspruch aus Kostenübernahme durch die Krankenkasse (sogenannte Genehmigungsfiktion – § 13 Abs. 3 a SGB V).

Immer selbst den Überblick behalten
Man sollte immer selbst die Übersicht darüber haben was der Arzt verschrieben hat. Deshalb ist die (bequeme) Beschaffung von Verordnungen über die Apotheke oder z. B. bei Hilfsmitteln, die für den Verbrauch bestimmt sind über Homecare-Unternehmen etc. nicht sinnvoll. Verordnungen mit allgemeinen Definition (nicht nur Dauerverordnungen) sind zu vermeiden. Zum einen wird dabei nicht exakt definiert was konkret geliefert oder durchgeführt werden soll und zum anderen können z.B. Versorger, die mit Pauschalen abgerechnet werden zuviel Einfluss auf Menge oder Qualität der sinnvoll zu verwendenden Produkte nehmen.

Der Autor Herbert Müller, Jahrgang 1946, ist selbst Stomaträger und wurde von der Selbsthilfe Stoma-Welt e.V. bevollmächtigt, in Fragen des Sozialrechts als Rechtsbeistand für betroffene Menschen tätig zu werden. So ist es Herbert Müller auch möglich, als Vertreter vor Gerichten usw. aufzutreten, nicht nur um zu zeigen, dass die Menschen in ihren Auseinandersetzungen mit „der Obrigkeit“ nicht alleine da stehen, sondern auch mit seinem Fachwissen im Sozialrecht Erfolge für die Menschen zu erzielen, die aufgrund ihrer Behinderung ohnehin genug Probleme haben. Mehr über Herbert Müller und seine Funktion als Sozialrechtsbeistand hier: Rechtsbeistand in Fragen des Sozialrechts

Bildquelle: Kurt F. Domnik / pixelio.de

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