In its decision of 23 January 2025, the Federal Supreme Court partially upheld the appeal filed by several healthcare insurers, represented by santésuisse, who had challenged the decision of the Arbitration Court for Healthcare Insurance Disputes (Tribunal arbitral des assurances) of the Canton of Geneva. The case centered on the repayment for uneconomical treatments provided by an independent physician specializing in general internal medicine. The dispute revolved around the issue of «polypragmatic billing» («Überarztung»), specifically the alleged breach of economic efficiency standards.

The appellants contended that the cantonal court had failed to correctly apply the required methodology for analyzing the economic efficiency of the treatments in question. In response, the court examined the relevant legal framework for assessing the economic efficiency under Art. 56 of the Health Insurance Act (Krankenversicherungsgesetz, KVG). According to the KVG, services covered by compulsory health insurance must be effective, appropriate, and economical (Art. 32 para. 1 KVG). The service provider must ensure that the services rendered are in the interest of the insured individual and necessary for the treatment (Art. 56 para. 1 KVG).

The Federal Supreme Court clarified that a physician’s economic practices must be evaluated through a combination of statistical and analytical methods, in a two-step process: The first step is a statistical regression analysis that relates current patient-related morbidity factors and new factors to unchanged provider-related factors. This is followed by an individual case analysis in which the provider must be able to demonstrate objectively and comprehensibly the practice-specific factors not included in the regression analysis that differentiate their practice from the comparison group and lead to a higher regression index value. However, in this case, the court found that the required individual case analysis had not been carried out. As a result, the cantonal court had incorrectly ordered repayment without completing this critical second phase of the review.

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