31 August 2024 – In its decision of 12 December 2023, the Federal Supreme Court partially approved the appeal of a doctor who had appealed against the decision of the Cantonal Arbitration Court for Health Insurance Disputes regarding repayment for uneconomical treatment. The «polypragmatic billing» («Überarztung») respectively a violation of economic efficiency requirement was disputed.

The Court has ruled on the performance audit of doctors. The case centred on the question of whether the self-dispensing of medicinal products by doctors leads to higher costs and whether this practice peculiarity must be taken into account in the performance audit.

In principle, the services covered by compulsory health insurance must be effective, appropriate and economical (Article 32 para. 1 Health Insurance Act (Bundesgesetz über die Krankenversicherung, KVG)). The service provider must limit its services to what is in the interest of the insured person and necessary for the purpose of treatment (Article 56 para. 1 KVG). «Polypragmatic billing», as claimed by the opposing party (26 health insurance companies), occurs when a doctor charges considerably more than other doctors in the same area without being able to claim any special features. Cost-effectiveness can be verified using either the statistical method (comparison of average costs), the analytical method (case-by-case examination), or a combination of both methods.

The Court held that the complainant was right in arguing that the screening as such did not in itself establish uneconomic treatment and therefore could not form the basis of a claim for reimbursement. Only a complete and case-by-case examination, taking into account in particular the individual characteristics of the medical practice, could determine whether the economic efficiency of service provision has actually been violated within the meaning of Article 59 KVG and therefore form the basis of a claim for reimbursement before Cantonal Arbitration Court for Health Insurance Disputes (see Article 59 para. 2 KVG). In the present case the case-by-case examination was not carried out in full. As a result, the basis for the decision of the previous court was incomplete. The appellant had therefore rightly criticized the fact that the opposing party respectively the Cantonal Arbitration Court for Health Insurance Disputes (Kantonales Schiedsgericht in Sozialversicherungsstreitigkeiten) had not fully implemented the individual case analysis as the second part of the performance audit. This constituted a violation of Article 56 KVG.

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