In its decision 9C_132/2022 and 9C_134/2022 of 27 May 2025, the Federal Supreme Court partially upheld the appeal filed by doctor A. regarding the reimbursement of payments made under compulsory health insurance. The Arbitration Tribunal for Social Security disputes in the Canton of Bern had upheld the claims filed by several health insurers through santésuisse alleging over-treatment by doctor A. and ordered him to reimburse the plaintiffs.

According to the tariff partners, the screening method as the first step of the economic efficiency review consists of a regression analysis to determine the individual case value (regression index) and a comparison between this and the group case value. The (provisional) case value of the service provider being reviewed is determined using a two-stage regression analysis. The tariff agreement establishes the following morbidity indicators at the first stage (relating to patients): age, gender, pharmaceutical cost groups (PCG), franchises, and hospital or nursing home stays in the previous year. At the second stage, the factors “specialist group” and “location canton” relating to the service provider are added.

The complainant objected to the lack of homogeneity of the comparison group, the use of an incorrect pharmaceutical cost group list, and an incorrect determination of the tolerance margin.

The court made reference to its jurisdiction that was published in the meantime (9C_199/2022 of 29 April 2025, see our publication here) and held that the relevant comparison group was determined by the specialist title (i.e. “general internal medicine”). The specific characteristics of the service providers (practice focus, etc.) should primarily be taken into account in the context of the individual case review and not as a question of the correct composition of the comparison group.

Furthermore, the court held that the index value determined in the screening procedure was only decisive for determining uneconomic efficiency. If certain PCGs that are not included in the list used actually and significantly provide a more accurate picture of the morbidity of the patient group, the relevant data could be evaluated as part of the individual case review.

Regarding the calculation of the reimbursement, the court also referred to its jurisdiction in decision 9C_199/2022 of 29 April 2025. The basis for the claim for reimbursement, therefore, is limited to the total direct costs. However, because of the necessity to consider the direct and induced costs as a whole, the reimbursement rate and amount are calculated on the basis of the total cost index. Hence, the formula is: Total direct costs multiplied by the quotient of the total cost index adjusted for the tolerance range and the quota for special circumstances in practice (minus 100) and the (unadjusted) total cost index.

As a result, the court referred the case back to the Arbitration Tribunal for a new decision.

For more information, see here.