Clinic & Insurer Communication

The two billing systems: Tiers garant and Tiers payant

Swiss healthcare uses two distinct billing models, and which one applies to you has a significant effect on whether you see a bill at all:

• Tiers garant (you pay first): The clinic sends the invoice to you. You pay it in full, then submit it to your insurer for reimbursement. Your insurer calculates your franchise and Selbstbehalt, deducts these from the claim, and reimburses you the difference. This is the most common model for GP and specialist outpatient care.
• Tiers payant (insurer pays directly): The clinic sends the invoice directly to your insurer. The insurer settles the invoice and sends you a statement showing what was paid and what (if any) portion you owe under your franchise/Selbstbehalt. Hospitals and pharmacies typically use this model.

In the tiers garant model, the patient receives the full invoice and has the responsibility to submit it to the insurer. This is why you should never discard a medical invoice without checking it carefully — you need to submit it to get your reimbursement.

How billing flows in practice

For a typical outpatient GP or specialist visit under tiers garant:

1. You attend the appointment. Your insurance card is scanned at reception.
2. The clinic prepares an itemised invoice (typically within 2–4 weeks) using the Tarmed billing code system.
3. The invoice is sent to you by post. It lists each billing position, the point value, and the total amount in CHF.
4. You submit the invoice to your insurer — either by post, via the insurer's app, or by scanning it online.
5. The insurer reviews the claim: checks whether all billed positions are KVG-covered, calculates your remaining franchise and Selbstbehalt, and prepares a reimbursement.
6. If you have met your franchise, the insurer pays the clinic directly (or reimburses you if you have already paid). If you have not yet met your franchise, the insurer confirms the amount you owe and you pay the clinic directly.

Electronic health card and billing

The Krankenkassenkarte (insurance card) contains your insurance number, insurer identity, and in modern versions a chip. When it is scanned at a practice, the clinic can bill electronically. This reduces administrative error and speeds up the process. Carry your insurance card to every appointment — without it, billing may be delayed or require manual verification.

What happens if a claim is disputed?

Insurers can and do reject or partially reject claims. Common reasons:

• The treatment is not on the KVG list of covered services
• The billing code does not match the documented diagnosis
• The treatment required prior authorisation (Kostengutsprache) that was not obtained
• The provider is not KVG-accredited
• Administrative errors in the invoice itself

If your insurer rejects or reduces a claim, they must send you a written explanation (Rückweisungsentscheid or similar). You have the right to dispute this decision. The first step is contacting your insurer to ask for clarification. If you disagree with the outcome, you can escalate to the cantonal health authority or ultimately to the health court (Schiedsgericht).

Pre-authorisation (Kostengutsprache)

For expensive treatments, surgery, or certain medications, your insurer may require written pre-authorisation before they will cover the cost. This is called a Kostengutsprache (or garantie de paiement in French). Your clinic or specialist submits the request — patients do not do this themselves.

Approval takes 1–4 weeks. Treatment planned without a required Kostengutsprache risks non-payment by the insurer. Always confirm with your clinic whether pre-authorisation has been obtained for any significant planned procedure.