22 October 2025 – In its decision 9C_781/2023 of 9 September 2025, the Federal Supreme Court partially approved the appeal of a medical practitioner against the decision for restitution of the Arbitration Tribunal in Social Security Disputes of the Canton of Zurich. The arbitration tribunal upheld the claim brought by various health insurers, represented by the association Santésuisse, and ordered the medical practitioner to reimburse CHF 75’670 for inappropriate services. The reason given was the use of uneconomical treatment methods. The dispute arose over alleged uneconomic medical practice for the statistical year 2017, under Art. 56 and 59 Health Insurance Act (Bundesgesetz über die Krankenversicherung, KVG).

The court stated that services billed to the mandatory health insurance must be effective, appropriate, and economical (Art. 32 para. 1 KVG). It explained the different steps of the cost-effectiveness assessment, the first step being the screening method and the second step an individual case review. The court referred to its recent case law concerning the inclusion and conditions of induced costs in the cost-effectiveness assessment. According to this, a violation of the requirement of economical treatment exists when the total cost index per patient (including direct and induced costs), relative to the reference value after deducting the tolerance margin and the portion attributable to practice-specific factors exceeds 100. A refund may be required if this is also true with respect to the similarly adjusted index of direct costs. However, the refund itself is limited to the total direct costs.

The court concluded that the Arbitration Tribunal's calculation did not comply with the relevant requirements pursuant to the recent case law. For this reason, it referred the case back to the Arbitration Tribunal for reassessment.

For more information, see here. The Federal Supreme Court came to the same conclusion in its decision 9C_782/2023 of 9 September 2025, see here.