Annual total expenditure of the compulsory health insurance system amounts to CHF 40 billion. In Switzerland, the amount that a medical practice or hospital is allowed to invoice the compulsory health insurance system for a specific service is regulated. Under the Health Insurance Act (HIA), service providers and health insurers negotiate the remuneration together, record it contractually in tariff structures and get it approved by the authorities. One exception to this is the so-called official tariffs: for medication, laboratory analyses and aids, the relevant responsible office or department determines the remuneration.
Similar processes are encountered outside the compulsory health insurance in other areas where tariffs are applied, such as accident or disability insurance. In total, there are over 30 different tariff structures. Under the HIA, tariffs may cover no more than the effective and necessary costs for the efficient provision of services. This is a key requirement, which is referred to in this report as “reflecting reality”. For this purpose, tariffs must be regularly reviewed and adjusted to current circumstances.
Using selected tariffs, the SFAO examined the processes in the area of compulsory health insurance which are intended to ensure that costs reflect reality. The aim of the audit was to assess whether the Confederation is appropriately equipped to ensure that costs in compulsory health insurance reflect reality, and whether it actually uses its powers. The audit revealed that, for outpatient care, there are no binding mechanisms for reviewing tariff structures. The Confederation can only exert a limited influence. The HIA allows the contracting parties a great deal of freedom. This need not be a problem per se, so long as both sides are interested in finding a solution. Yet, different interests often lead to delays or even blockages. This can result in services being remunerated at excessive prices: for example, the treatment time needed may have been significantly reduced by technical progress since the tariff structure was introduced. The SFAO found that the Confederation has exerted more influence in recent years, but it has not yet fully exploited its powers to ensure that costs reflect reality.<\/p>\n","protected":false},"featured_media":0,"menu_order":0,"template":"","audit_category":[75],"audit_type":[51],"class_list":["post-37432","audit","type-audit","status-publish","hentry","audit_category-health","audit_type-audit"],"acf":{"audit_lang":null,"audit_numbers":[{"audit_number":"23653"}],"audit_office":[1246],"audit_office_text":"","audit_date":"20250402","bgo":false,"keywords":"","audit_office_local":""},"yoast_head":"\n