Tariffs in the Swiss health care system
In the Swiss healthcare system, there are various tariff systems that serve as the basis for billing, depending on the case. Primarily, a distinction can be made between the reimbursement or the tariff structures of outpatient and inpatient treatment. In outpatient cases, the patient spends neither the night before nor the night after treatment in the hospital. Inpatient cases, on the other hand, involve a stay in a hospital of at least 24 hours or an overnight stay with bed occupancy.
Legal framework
The Federal Health Insurance Act (KVG) states in Art. 24, Para. 1 that compulsory health insurance covers, among other things, the costs of benefits in the event of illness, accidents and maternity. However, the benefits must meet the so-called WZW criteria and thus be effective, expedient and economical (Art. 32 Para. 1 KVG).
It is further stipulated that the invoices of the service providers must be prepared according to tariffs or prices (Art. 43 Para. 1). With regard to tariffs, it is also defined that both a time-based tariff, an fee-for-service tariff and a flat-rate tariff can be used for calculating the reimbursement (Art. 43 Para. 2 KVG).
Inpatient tariffs
In the area of inpatient treatment (actusomatics, rehabilitation, psychiatry), uniform nationwide tariff structures are to be created by means of flat rates (usually per-case flat rates) (Art. 49 Para. 1 KVG). This led to the development of the currently valid inpatient tariffs SwissDRG (acute somatic), TARPSY (psychiatry) and ST Reha (rehabilitation). Learn more about the inpatient tariffs on the corresponding knowledge page:
Outpatient tariffs
In the outpatient sector, physician services have been reimbursed by the TARMED fee-for-service tariff since 2004. Since various attempts to update the now outdated TARMED catalog have failed, the switch to new tariff structures in the outpatient sector is imminent. The cost containment measures adopted in 2021 define that new fee-for-service tariffs and outpatient flat rates must also be based on uniform tariff structures throughout Switzerland. If no agreement is reached between the tariff partners, the Federal Council can define the tariff structure (Art. 43 Para. 5 KVG).
Currently, it is assumed that TARMED will be replaced by a combination of outpatient flat rates with a new fee-for-service tariff called TARDOC from 2025. The outpatient flat rates will be structured similarly to the inpatient per-case flat rate systems. They will include not only physician services, but also reimbursement for medications or medical supplies, such as implants. Learn more about the different outpatient rate systems and the latest developments on our outpatient rate knowledge pages.
Coding
The central basis for the individual service-based tariff systems is the coding of the individual cases. This makes it possible to store both diagnoses and treatments, or procedures, in a standardised way for each case. Based on the coding and other data (e.g. demographic and administrative characteristics or cost data) of the individual cases, the tariffs can be further developed on the basis of data and the cases can be reimbursed accordingly. Learn more about coding in the Swiss health system and the central role of the two catalogues ICD and CHOP on the corresponding knowledge pages: