Cash payments, or direct payments from patients outside public health insurance

When can you ask a patient for direct payment?

Direct payment can only be requested from a patient in situations permitted by law. These include, for example, the following situations:

• Regulatory fee (emergency): This is the only currently applicable regulatory fee – CZK 90 for using medical emergency services or dental emergency services. This fee is collected by the provider from the patient by law. (Note: The fee is not paid in exceptions stipulated by law, e.g., when the patient is subsequently hospitalized.)
• Co-payments for partially covered services: If a healthcare service is only partially covered by insurance, the patient is obliged to pay the difference up to the full price. This typically includes co-payments for partially covered medicinal products, medical devices, or dental products – the patient pays the part of the price that exceeds the insurance company's set reimbursement.
• Healthcare services completely uncovered: Some services are not covered by public health insurance at all. Under the law, the insurance company does not cover, in particular, procedures performed in the personal interest at the patient's request, the purpose of which is not to improve or maintain their health condition.

This includes, for example, various certificates and examinations upon request (certificates for a driver's license, occupational health examinations beyond the mandatory scope, sports examinations, etc.), cosmetic and aesthetic procedures without medical indication, vaccinations not covered by insurance, and other services listed in the annex to Act No. 48/1997 Coll. You can charge the patient in full for these procedures, as they are not covered by public insurance.

• Care at a non-contracted provider: Every patient has the right to choose a healthcare provider who has a contract with their health insurance company. However, if a patient voluntarily seeks care from a provider who does not have a contract with their insurance company (a "non-contracted" doctor), they waive coverage from public insurance and pay for all such care themselves. Therefore, if you do not have a contract with a specific insurance company, you can treat its insureds for direct payment.

The only exception is emergency care in the event of a threat to life or health – you must provide this to the patient without being able to demand payment from them, in which case you bill the insurance company, and they will reimburse even a non-contracted facility.

• Above-standard voluntary services at the patient's request: You can also offer the patient so-called above-standard services – i.e., something extra compared to standard covered care. Typically, this involves higher comfort or premium materials. Example: providing a premium single room in a hospital, using better materials or devices (e.g., a higher-quality intraocular lens during cataract surgery, which is not normally covered by insurance), or above-standard examinations beyond standard procedures. However, it is crucial that the patient must always have a choice – they must not be forced to pay for above-standard services, and a covered care option must exist.

The provider is obliged to provide the necessary care covered by insurance, even if the patient refuses the offered above-standard service. Furthermore, the difference between standard and above-standard care must not lie in the quality or effectiveness of the treatment – a better treatment outcome cannot be conditioned on paying for above-standard services. Above-standard services should remain at the level of supplementing care (comfort, extra choice), not ensuring more effective treatment only for paying patients. If you comply with these conditions, the above-standard service for direct payment is legal.

The situations mentioned above summarize the legitimate options for direct payments outside of public insurance. In all cases, however, the patient must be clearly informed in advance of what they are paying for and for what reason.

Laws and Case Law

The issue of direct payments is regulated mainly by two key laws – the Act on Public Health Insurance (No. 48/1997 Coll.) and the Act on Healthcare Services (No. 372/2011 Coll.). It has also been influenced by case law, in particular the findings of the Constitutional Court on the issue of standard vs. above-standard care. What do these regulations mean for you as a provider?

Act No. 48/1997 Coll., on Public Health Insurance, defines the entitlements of insured persons and the scope of covered care. Key is the provision of Section 11(1)(d), according to which the insured person has the right to the provision of covered services, and the provider must not accept any payment from the patient for these services. The exceptions to this rule are precisely the regulatory fees, co-payments, and payments for uncovered services mentioned above. The provision of Section 15 regulates the scope of covered care with reference to the annexes to this Act, where, for example, specific medical procedures (Annex No. 1) are listed that are not covered by health insurance, or are covered only under certain conditions. For your practice, knowledge of the procedures covered by public health insurance is essential.

Act No. 372/2011 Coll., on Healthcare Services, sets out the obligations of providers when providing healthcare services. The provision of Section 45(2)(a) imposes an obligation on the provider to inform the patient in advance of the price of the healthcare service if it is not covered (or only partially covered) by public insurance, and also to issue an invoice for services paid in this way.

According to letter b) of the same provision, it is the provider's duty to create and make available to patients a price list of all provided healthcare services that are not covered or are only partially covered. In practice, you should therefore have an up-to-date list of prices for uncovered procedures visibly posted (e.g., in the waiting room or on the website) and inform the patient of its price before providing each uncovered service – ideally through a written informed consent. After payment, you then issue a receipt to the patient.

The regulation of direct payments has also come before the Constitutional Court in the past. For example, in 2013, it annulled the legislature's attempt to firmly define "standards and above-standards" of healthcare (finding Pl. ÚS 36/11). It emphasized that the difference between standard and above-standard care must not lie in quality and effectiveness – insured persons are entitled to effective treatment without direct co-payments.

In an earlier finding (Pl. ÚS 14/02), the court confirmed that the prohibition of direct payment applies only to care covered by insurance to the specified extent, but nothing prevents the provision of additional services for payment beyond this care. The case law thus supports the interpretation that above-standard services can be offered, but there must be no disruption of the patient's entitlement to free basic care.

In practice, some controversial fees have appeared in recent years (e.g., "registration fees" for accepting a patient into care or a fee for a priority appointment). The Ministry of Health has repeatedly declared that such payments are contrary to the law – the insurance company guarantees accessible care, and paying for an earlier appointment or registration with a doctor itself is not permissible. When assessing direct payments, it is therefore necessary to proceed cautiously and always verify whether it is not a hidden charge for something that should be free.

Risks of Incorrect Procedure

The introduction of direct payments from patients without a thorough knowledge of the rules can lead to serious problems. What risks do you face if you request payments from patients in violation of the rules?

The Act on Healthcare Services directly regulates the patient complaint mechanism – a patient can file a complaint directly with you on the grounds that they were requested to pay for something in violation of the law, and subsequently with the regional authority (Prague City Hall), i.e., the relevant administrative authority that supervises the performance of healthcare services. This administrative authority may initiate administrative proceedings on suspicion of a breach of the provider's obligations.

Therefore, if you fail to inform the patient of the price of the services provided to them, do not have an established and accessible price list, or do not issue a receipt to the patient for the paid services, this conduct of yours may be assessed by the administrative authority as an administrative offense. If the offense is proven, the administrative authority may impose a fine of up to CZK 50,000.

The relevant administrative authority may even revoke the authorization to provide healthcare services if the provider has repeatedly requested payment from patients for healthcare services in violation of the Act on Public Health Insurance.

Currently, an amendment to the Act on Healthcare Services is being discussed by legislators, which explicitly introduces further offenses, particularly in cases where a provider requests payment for the provision of healthcare services or related services to the extent that these services are covered by public health insurance. Such unlawful conduct may be sanctioned with a fine of up to CZK 1,000,000.

If you have a contract with an insurance company, unauthorized collection of payments from its insureds constitutes a breach of contractual terms. The insurance company may even terminate the contract if, in violation of legal regulations, you request financial payment from its insureds for covered services or for accepting their insured into care. Health insurance companies are already receiving complaints and inquiries from patients regarding fees and are actively addressing them. For example, VZP states that it records dozens of submissions per year, most frequently in the fields of dentistry and gynecology.

In extreme cases, the patient may legally demand the paid amount back if they find out they paid unjustifiably. Under the law, the insured person has the right to free covered care, and any additional payments (outside of statutory co-payments and fees) could be assessed as unjust enrichment on the part of the provider. Patients also have access to a statement of procedures paid for them by the insurance company – they can request it or view it online. It is therefore not difficult to detect that a provider received payment from the insurance company for a procedure for which they simultaneously collected money from the patient.

Practical tips for the correct setup of direct payments

• Verify what insurance covers and what it does not: Before introducing any direct payment, always find out whether the given procedure or service is among those covered by public insurance. If so (even if only under certain conditions), do not collect a fee, unless it is a statutory regulatory fee or co-payment. Conversely, for procedures explicitly excluded from coverage (personal requests of the patient, above-standard services), you have a free hand.
• Have a clear and public price list: Prepare a detailed price list of all uncovered and partially covered services and publish it in a visible place (waiting room, reception) and on the website. Update the price list regularly. The patient must have the opportunity to find out in advance how much and for what they might pay.
• Inform the patient in advance and in writing: As soon as you know that the patient intends to use an uncovered service (e.g., wants premium material or an extra procedure), explain the price and conditions to them in advance. It is ideal to have the patient sign an informed consent, stating that they have been informed of the price, voluntarily agree to the provision of the service for direct payment, and are aware that the procedure is not covered by insurance.
• Do not request payments that could indirectly limit the availability of care: Avoid any fees that condition the provision of standard care. For example, a fee for registering a new patient, membership in a clinic program, or payment for an earlier appointment. It is better not to introduce such fees at all. If you offer a premium reservation (e.g., booking for an exact time for a fee), it must be completely voluntary, and it must not happen that a patient who does not pay is refused or postponed.
• Issue receipts and record payments: Properly record every direct payment from a patient and issue an accounting document. The patient receives a confirmation of payment, which strengthens trust and is also your protection (you have proof that the payment was collected for a specific uncovered procedure). In the event of an inspection, you will prove that everything is transparent.
• Train staff and communicate: Make sure all your healthcare professionals and receptionists know the rules. They must know which procedures are covered by insurance and when to collect money if necessary. This will prevent situations where, for example, a nurse accidentally requests payment for something that is covered.
• Consult with experts in case of uncertainty: If you encounter a new situation or doubt, do not hesitate to consult a lawyer specializing in medical law. For example, the Czech legal team at ARROWS can advise you on whether a planned VIP program for patients or, for example, a fee for an above-standard consultation is in line with current legislation. Prevention will help you avoid sanctions. Similarly, if a dispute with a patient or insurance company already arises, it is advisable to seek professional help – a friendly solution can often be found before the problem escalates.

Final Summary

The introduction of direct payments outside of public health insurance can bring a higher standard of services to your facility and more satisfied patients who are happy to pay extra for above-standard care. At the same time, however, this is an area where any mistake can have serious legal consequences.

The key to success is therefore knowledge of the rules and careful setup of processes. As we have shown, the legislation precisely defines when and how you may accept payments from patients – always ensure voluntariness, prior information of the patient, and transparency. Avoid any "gray areas" and rather ask experts in case of uncertainty.

The ARROWS law firm is ready to be your partner in this regard. Our experienced Czech legal team regularly handles medical law matters – from setting up price lists and contracts with insurance companies to representation during inspections or disputes. If you are not sure whether your procedure for collecting direct payments complies with current laws under Czech legislation, please contact us at consultation@arws.cz. We will be happy to review your internal regulations, advise on the optimal solution for above-standard services, or train you on the new legislation.

Do not underestimate the risks, but do not reject the opportunities either – with legal support, you can offer above-standard care to your patients legally and without worries. We believe that with this overview, you will navigate the issue of direct payments with more confidence. Our Prague-based law firm, ARROWS, stands by your side and will help you find the right path so that your healthcare facility can prosper to the benefit of both you and your patients.