Some doctors and hospitals have not concluded new contracts with health insurers. Which could have painful consequences for policyholders.
Anna Wanner et Doris Kleck / ch media
From 2025, health funds will not be able to finance supplementary insurance services only if the additional costs are justifiable and transparent. This requirement was imposed in 2020 by the Federal Financial Market Supervisory Authority (Finma), which supervises both banks and the private insurance sector.
This measure could have unpleasant repercussions for people insured privately or semi-privately: as early as January, these patients could face a large portion of their hospital bill. If the additional costs are not invoiced in a transparent and justifiable manner, the insured will have to pay them in part or in full.
What has changed?
After Finma's intervention, health insurers, under the aegis of the Swiss Insurance Association (ASA), imposed their own rules to save the supplementary insurance sector. Eleven principles have been developed, valid since 2022, and integrated into the new contracts negotiated with hospitals and doctors. The branch has given itself a transition period until the end of 2024.
The insurers' association describes “intense efforts” to implement the new requirements. Around 1,700 contracts were renegotiated and adapted to the standards. However, many hospitals are struggling to comply with the new regulations. The association estimates that 20 to 30% of doctors and hospitals remain in a situation without a contract.
But the rules are clear: from 2025, without a compliant contract, additional services can only be reimbursed to a limited extent.
More delicate situation among French-speaking people
Health insurers strive to eliminate unregulated contractual situations to avoid irritating policyholders. Negotiations will therefore continue even after the deadline has expired. “We are on the right track,” says Beni Meier of KPT insurance, “but we need more time in French-speaking Switzerland”.
Helsana also claims to be trading at full speed. But Daniela Zimmermann-Fehr, head of purchasing at Helsana, admits there could be more no-contract situations in January than there are today. “It’s unpleasant for our policyholders, who pay a premium for additional service,” she says.
“But sometimes a temporary state without a contract is better to be able to impose pricing requirements”
Daniela Zimmermann-Fehr
At Groupe Mutuel, out of around 140 contractual situations with clinics and hospitals, two negotiations for the year 2025 have failed and one contract is expiring. “We also still have a dozen unresolved situations”specifies Lisa Flückiger, spokesperson for the company.
The situation is particularly delicate in the Lake Geneva region, as confirmed by various insurers. In the cantons of Vaud and Geneva, accredited doctors are grouped into cantonal associations. Price negotiations are done through these powerful medical companies. Groupe Mutuel insurance has, however, reached an agreement with the Geneva medical company.
“This complicates negotiations, because you have to deal with a larger group, and because a certain lack of understanding of tariff structures persists”
Lisa Flückiger
Blacklists for hospitals?
To enable private patients to have a hospital stay without unpleasant surprises, the association recommends contacting their health insurance as soon as possible. Customers can ask whether a hospital is, for example, on a “blacklist” because it does not have a contract with the health insurance company. This allows you to know if the planned treatment or hospital stay is covered – or if you need to turn to another establishment. Some insurers already publish such lists online and indicate alternatives wherever possible.
Daniela Zimmermann-Fehr emphasizes that medical care is not affected. These are covered by compulsory health insurance.
Even if it does not seem like it at first glance, Finma acts in the interest of policyholders in addition: premiums are sometimes misappropriated, services billed twice or treatments overestimated. This is all illegal. Finma therefore requires that the additional costs be clearly differentiated from the usual benefits of compulsory basic insurance.
Translated and adapted from German by Tanja Maeder
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