One of the main tasks of all health insurers admitted in Switzerland is the systematic control of invoices. This process ensures that only legal services billed by doctors, hospitals, pharmacists and other providers of medical services are covered by health insurance. The precise control of bills by the health insurers and the resulting savings help to contain the rising costs of health and premiums.
Extrapolated to the whole industry, the savings achieved through the control of invoices in the mandatory health insurance amounted to around CHF 3 billion in 2016. Without systematic monitoring of benefits, average premiums would be 10% higher. This is the result of a survey done by the Institute for Economic Studies Basel (IWSB) on behalf of santésuisse concerning the impact of invoice control.
Health insurers check the invoices received to determine whether the insured person has a corresponding cover and whether the benefit provider is entitled to provide the treatment concerned under this insurance. They also check whether the treatment is billed at the correct rate and can, therefore, be reimbursed. Wrongly inflated bills are rather rare. Errors or inaccuracies in the application of tariffs are by far the most common reason for rejecting invoices. The percentage of disputed invoices is particularly high for outpatient hospital treatment and emergency treatment abroad.
Sickness insurers are required by law to make sure if the invoiced services meet the criteria of efficiency, adequacy and economy. Today, this task could be done even better if the insurers had essential information in specific areas. In the ambulatory sector of hospitals and private practices, for example, the diagnosis is only very roughly indicated in the TARMED medical tariff, which is not the case when a stationary hospital stay is billed on the basis of SwissDRG system. santésuisse, therefore, requires, in the interest of the premium payers, targeted adjustments to the current legal framework conditions, in order to strengthen the control of benefits and further exploit the savings potential.
You can find the full article in French (change to German or Italian at the top of the page) here.
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