10. Mai 2024 – In its decision of 3 April 2024, the Federal Supreme Court partially upheld the appeal of Hospital A. against the decision of the Cantonal Arbitration Court for Health Insurance Disputes of the Canton of Basel-Stadt regarding the invoicing of the TARMED tariff item 39.5070 "MRI facial skull/paranasal sinuses" and 39.5050 "MRI neurocranium overview".

Hospital A. was ordered by the Cantonal Arbitration Court for Health Insurance Disputes to repay a total of CHF 1,688,511.34 to 28 health insurance companies for allegedly overcharging of MRI scans. The health insurers claimed that Hospital A. had systematically invoiced both an MRI of the neurocranium (overview) (tariff item 39.5050) and an MRI of the face and paranasal sinuses (tariff item 39.5070), even though only one of these services had been necessary. Hospital A. argued in front of the court that the Cantonal Arbitration Court for Health Insurance Disputes had based its decision on an unrepresentative sample of 40 cases, that the individual circumstances of each case had not been sufficiently taken into account and that in some of the cases for which it had been ordered to reimburse, the MRI scans had actually been medically necessary.

The court found that the sample of 40 cases used as a basis was too small and not representative of the entire population of cases. The sample represented only 0.37 % of the total cases and it was not clear how it had been compiled. Furthermore, the court criticised the fact that the individual circumstances of each case were not sufficiently taken into account. The question of whether both an MRI of the neurocranium (overview) and an MRI of the face and paranasal sinuses were necessary could not be answered in a generalised manner for all cases.

As a side note, the court also pointed out that the relative limitation period pursuant to Art. 25 para. 2 of the Federal Act on the General Part of Social Security Law (Bundesgesetz über den Allgemeinen Teil des Sozialversicherungsrechts; [in the version in force until the end of 2020 and applicable in the case at hand]) had been applied correctly by the Cantonal Arbitration Court for Health Insurance Disputes.

The court overturned the judgement of the Cantonal Arbitration Court for Health Insurance Disputes and referred the case back to it for reconsideration.

For more information, see here.