Electronic signatures in healthcare: Guidance for dentists

Digitization has revolutionized almost every area of life in recent years. But in Germany, development in some sectors is still lagging behind, especially in comparison with other countries. In healthcare in particular, digital progress is often held back by bureaucratic regulations that make efficient digital transformation difficult.

At this point, a brief illustration: The written form for fillings in the dental field in accordance with Section 28 (2) SGB V was established 27 years ago under the government of Helmut Kohl. At that time, 3% of the German population had Internet access via their modem, and smartphones were unthinkable. The Merkel government therefore introduced the electronic form in 2019 for fillings in the orthodontic field with Section 29 (7) SGB V. However, this was not regulated uniformly for all treatments and specialties.

Documents with written form requirement

Some dental practices are therefore unsure which documents still have to be signed in "written form", i.e. by hand, according to the current state of legislation and which can be signed digitally with Nelly without any concerns. In view of the fact that this responsibility and the documentation requirements fall within the dentist's area of responsibility, some practices are concerned about a loss of fees or want legal certainty.

This guidance is therefore intended to clarify which documents are clearly subject to a written form requirement at the present time according to the wording of the law:

Billing, Section 10 (6) GOZ

New patient's first signature for patient consents to submit data for billing purposes. (EWE - Billing Consent Form).

Honoar Agreement, Section 2 Para. 1,2 GOZ

This fee agreement is used if the factor of 3.5 is exceeded. This means: In the event of a deviating fee amount, the fee agreement must have been drawn up and signed by the patient in writing before the start of treatment.

This must be observed in particular for the fee agreement in accordance with Section 2 (1) and (2) GOZ:

• Conclusion of the agreement before the start of treatment
• Written form
• no flat rate agreement
• Note, reimbursement office may not reimburse everything
• Delivery of an impression to the patient

‍‍Requested services, Section 2 (3) GOZ

Demand services are all treatments that are not medically necessary. As with the fee agreement, a treatment and cost plan (TCP) must be prepared and signed in writing before the start of treatment. In particular, this treatment and cost plan must contain the service with the corresponding remuneration as well as a reference to the optional service, including a reference to possible non-reimbursement.

Examples of demand services:

• Filling replacement because tooth color is not pleasing (but filling is intact)
• New crown, because the shape is not pleasing (but crown margins are sufficent)
• Cosmetic tooth reshaping (e.g. closing an anterior gap)
• Second denture / travel denture
• Bleaching
• Tartar

‍‍AdditionalCost Agreement MKV Filling, Section 28 (2) SGB V

In the case of filling therapy, the patient can choose between a filling covered by the health insurance system and a filling with co-payment. Only in cases where the patient opts for a filling outside the scope of statutory health insurance coverage is the written form required. This is because in this case the patient bears the additional costs himself and must therefore sign this additional cost agreement before treatment begins.

Soon fewer bureaucratic hurdles in the healthcare system

The good news: In the future, more and more documents in Germany's dental practices will probably be able to be effectively digitally signed. The German government recently adopted key points of the Fourth Bureaucracy Relief Act (BEG IV). This aims to make electronic form or text form the standard form in the German Civil Code (BGB) and to use written form only as a substitute for electronic form.

In concrete terms, this means that electronic written form is to become the future standard in legal transactions. Numerous written form requirements will be abolished. In addition, the Act to Accelerate the Digitization of Healthcare (Digital Act - DigiG) and the Health Data Usage Act (Gesundheitsdatennutzungsgesetz - GDNG) will create the further framework for a modern and digitally supported healthcare system.

Please note that this guidance has been prepared for information purposes only, has no legally binding effect and does not constitute legal advice. In addition, this guidance document has been prepared only with regard to formal requirements under civil law. We have compiled this document based on extensive research and legal opinions. The ultimate responsibility for signing documents remains with the physicians themselves.