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

As a healthcare provider, you may face the dilemma of when you can ask a patient for direct payment and when payment from public health insurance must suffice. Imagine, for example, a private clinic that wants to offer a premium joint implant – the patient is willing to pay extra, but you are unsure whether this would violate regulations.

These questions are valid. Czech legislation sets clear rules: patients are entitled to care covered by insurance, and providers may not accept any payment from patients for such covered care. However, there are exceptions and situations permitted by law where payment may be required from patients.

In this article, we will explain in a clear and concise manner the options for direct payment for healthcare services outside the scope of public health insurance. You will learn when direct payment is legal, with specific examples, and also what risks are involved if the procedure is not followed correctly.

Author of the article: ARROWS (Mgr. Dita Zbožínková, LL.M., office@arws.cz, +420 245 007 740)

When can you ask a patient for direct payment?

As a general rule, you may not charge the patient directly for any care that falls within the scope of covered services – the costs are covered by the health insurance company (pursuant to Section 11(1)(d) of the Public Health Insurance Act). You may only request payment from the insured person if this is expressly permitted by another provision of the Public Health Insurance Act.

These include the following situations:

• Regulatory fee (emergency room): This is the only regulatory fee currently in force –
• CZK 90 for the use of emergency medical services or emergency dental services. This fee is collected from the patient by the provider in accordance with the law. (Note: The fee is not payable in cases specified by law, e.g. if the patient is subsequently hospitalized)
• Additional payments for partially covered services: If a healthcare service is only partially covered by insurance, the patient is required to pay the difference to the full price. This typically includes additional payments for partially covered medicines, medical devices, or dental products – the patient pays the portion of the price that exceeds the amount covered by the insurance company.
• Health services not covered at all: Some services are not covered by public health insurance at all. The law stipulates that the insurance company does not cover, in particular, procedures performed in the personal interest of the patient at their request, the purpose of which is not to improve or maintain their health.

These include, for example, various certificates and examinations on request (certificates for driving licenses, medical examinations beyond the scope of mandatory examinations, examinations for sports, 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 the full amount for these services, as they are not covered by public insurance.

• Care from 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 so-called “non-contract” doctor), they waive their right to reimbursement 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 insured persons for direct payment.

The only exception is emergency care in life-threatening situations – you must provide this to the patient without charging them, and then bill the insurance company, which will reimburse you even if you are not contracted to provide care to that patient.

• Voluntary services above the standard level at the patient's request: You can offer the patient
• so-called above-standard services – i.e., something extra compared to standard care. Typically, this involves greater comfort or above-standard materials. Examples include providing an above-standard single room in a hospital, using better materials or equipment (e.g., higher-quality intraocular lenses for cataract surgery, which are not normally covered by insurance), or above-standard examinations beyond the scope of standard procedures. However, it is important that the patient always has a choice – they must not be forced to pay for above-standard care, and there must be a covered care option available.

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

The above situations summarize the legitimate options for direct payments outside public insurance.

In all cases, however, the patient must be clearly informed in advance of what they are paying for and why.

Laws and case law

The issue of direct payments is regulated in particular by two key laws – the Public Health Insurance Act (No. 48/1997 Coll.) and the Health Services Act (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. The key provision is Section 11(1)(d), according to which the insured person is entitled to the provision of covered services and the provider may not accept any payment from the patient for these services. Exceptions to this rule are precisely those regulatory fees, additional payments, and payments for non-covered services mentioned above. Section 15 regulates the scope of covered care with reference to the annexes to this Act, which specifically list, for example, medical services (Annex 1) that are not covered by health insurance or are covered only under certain conditions.

For your practice, it is essential to know which services are covered by public health insurance.

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

According to letter b) of the same provision, it is the provider's obligation to create and make available to patients a price list of all health services provided that are not covered or are only partially covered. In practice, this means that you must have a current list of prices for non-covered services clearly displayed (e.g., in the waiting room or on the website) and inform the patient of the price of each non-covered service before providing it—ideally with written informed consent. After payment, you issue a receipt to the patient.

Who to contact:

The regulation of direct payments has also been brought before the Constitutional Court in the past. In 2013, for example, it overturned an attempt by lawmakers to define “standard and above-standard” healthcare (ruling Pl. ÚS 36/11). It emphasized that the difference between standard and above-standard care must not be in quality and effectiveness – insured persons are entitled to effective treatment without direct additional payments.

In an earlier ruling (Pl. ÚS 14/02), the court confirmed that the ban on direct payments applies only to care covered by insurance within the specified scope, but nothing prevents the provision of additional services beyond this scope for a fee. The case law thus supports the interpretation that above-standard services may be offered, but this must not interfere with the patient's right to free basic care.

In practice, some controversial fees have emerged in recent years (e.g., “registration fees” for admitting a patient to care or a fee for a priority appointment). The Ministry of Health has repeatedly stated that such payments are contrary to the law—the insurance company guarantees accessible care, and it is not permissible to pay for earlier appointments or for registration with a doctor. When assessing direct payments, it is therefore necessary to proceed with caution and always verify that this is not a hidden charge for something that should be free.

Risks of incorrect procedure

Introducing direct payments from patients without a thorough knowledge of the rules can lead to serious problems. What are the risks if you ask patients for payments that are contrary to the rules?

The Health Services Act directly regulates the patient complaint mechanism – a patient may file a complaint directly with you on the grounds that they were required to pay something in violation of the law, and subsequently with the regional authority (the Prague City Hall), i.e., the competent administrative authority that supervises the provision of health 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 about the price of the services you provide, do not have a price list available, or do not issue a receipt to the patient for the services provided, your actions may be considered an offense by the administrative authority. If an offense is proven, the administrative authority may impose a fine of up to CZK 50,000.

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

Legislators are currently discussing an amendment to the Healthcare Services Act, which explicitly introduces additional offenses, in particular in cases where the provider demands payment for the provision of health services or related services to the extent that these services are covered by public health insurance. Such unlawful conduct will be punishable by a fine of up to CZK 1,000,000.

If you have a contract with an insurance company, the unauthorized collection of payments from its insured persons constitutes a breach of the contractual terms and conditions. The insurance company may even terminate the contract if you demand financial compensation from its insured persons for services covered by insurance or for accepting their insured persons into care in contravention of the law. Health insurance companies are already receiving complaints and inquiries from patients about fees and are actively addressing them. For example, VZP reports that it receives dozens of complaints each year, most often in the fields of dentistry and gynecology.

In extreme cases, patients may seek legal recourse to recover the amount paid if they find that they have paid unjustifiably. By law, insured persons are entitled to free care, and any additional payments (other than statutory co-payments/fees) could be considered unjust enrichment on the part of the provider. Patients also have access to a statement of services paid for by their insurance company, which they can request or view online. It is therefore not difficult to detect that a provider has collected payment from the insurance company for a service for which they have also charged the patient.

We have some practical tips for setting up direct payments correctly:

• Check what your insurance covers and what it doesn't: Before introducing any direct payments, always find out whether the service is covered by public insurance. If it is (even if only under certain conditions), do not charge a fee, unless it is a statutory regulatory fee or surcharge. On the other hand, you have a free hand with services that are expressly excluded from reimbursement (personal requests from patients, above-standard services).
• Have a clear and public price list: Prepare a detailed price list of all non-covered and partially covered services and display it in a visible place (waiting room, reception) and on your website. Update the price list regularly. Patients must be able to find out in advance how much they will have to pay and what for.
• Inform patients in advance and in writing: As soon as you know that a patient intends to use a non-covered service (e.g., they want above-standard materials or additional services), explain the price and conditions to them in advance. Ideally, have the patient sign an informed consent form 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 service is not covered by insurance.
• Do not require payments that could indirectly limit access to care: Avoid any fees that make standard care conditional. For example, fees for registering a new patient, membership in a clinic program, or payment for an earlier appointment. It is best not to introduce such fees at all. If you offer premium booking (e.g., booking an exact appointment time for a fee), this must be entirely voluntary and patients who do not pay must not be refused or postponed
• Issue receipts and record payments: Properly record every direct payment from a patient and issue an accounting document. The patient will receive confirmation of payment, which strengthens trust and also protects you (you have proof that payment was collected for a specific unpaid service). In the event of an inspection, you can prove that everything is transparent.
• Train staff and communicate: Make sure that all your medical staff and receptionists are familiar with the rules. They need to know which services are covered by insurance and when to collect money. This will prevent situations where, for example, a nurse accidentally requests payment for something that is covered.
• Consult experts if you are unsure: If you encounter a new situation or have any doubts, do not hesitate to consult a lawyer specializing in healthcare law. For example, ARROWS lawyers can advise you on whether a planned VIP program for patients or, for example, a fee for above-standard consultations is in line with current legislation. Prevention will help you avoid penalties. Similarly, if a dispute arises with a patient or insurance company, it is advisable to seek professional help—often, an amicable solution can be found before the problem escalates.

Introducing direct payments outside of public health insurance can bring your facility a higher standard of service 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 process design. As we have shown, the legislation precisely defines when and how you may accept payments from patients – always ensure that payments are voluntary, that patients are informed in advance, and that the process is transparent. Avoid any “gray areas” and, if in doubt, consult experts. ARROWS Law Firm is ready to be your partner in this regard.

Our experienced lawyers regularly deal with healthcare law issues, from setting price lists and contracts with insurance companies to representation in inspections and disputes. If you are unsure whether your direct payment collection procedure complies with current laws, please contact us. We will be happy to review your internal regulations, advise you on the optimal solution for above-standard services, or train you in new legislation. Do not underestimate the risks, but do not reject the possibilities either – with legal support, you can offer your patients above-standard care legally and without worry. We believe that this overview will help you navigate the issue of direct payments with greater confidence. Our law firm ARROWS is on your side and will help you find the right path so that your healthcare facility can prosper for the benefit of you and your patients.

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