Outpatient Treatment and Insurer: What Does Who Cover?
For medical treatments, a distinction is made between outpatient and inpatient benefits. Compando explains what an outpatient treatment costs, what the insurer covers and when "outpatient before inpatient" applies.
1. What is an outpatient treatment?
An outpatient treatment takes place without overnight stay in the hospital or in a clinic. You come for examination or treatment and return home the same day. With an inpatient treatment, on the other hand, you stay at least one night in the hospital.
Examples of outpatient treatments
- Doctor visits
- Therapies at physio- and ergotherapists or in speech therapy practices
- Smaller gynaecological interventions
- Nutrition and diabetes counselling
- Treatments by nursing professionals
- Investigations in laboratories
- X-ray examinations
Whether a treatment takes place outpatient or inpatient is decided by the treating doctor according to medical necessity. The distinction determines which insurance bears which costs.
2. Outpatient treatment: which costs does basic insurance cover?
Mandatory basic insurance covers an outpatient treatment under the Health Insurance Act (KVG) when three conditions are fulfilled: the treatment is medically prescribed, it is in the KVG mandatory catalogue and it fulfils the WZW criterion (medically effective, appropriate, economical). If these conditions are fulfilled, basic insurance pays the treatment minus your cost participation from deductible and co-payment.
Not covered are wellness, fitness contributions as well as complementary medicine by non-medical therapists. Medical complementary medicine (acupuncture, homeopathy, anthroposophic medicine, classical Chinese phytotherapy and TCM) is on the other hand covered in basic insurance if the doctor has a recognised additional continued training. For benefits outside the KVG catalogue, a supplementary insurance takes effect.
Choose outpatient supplementary insurance by need
Compando shows which supplementary insurance covers complementary medicine, extended therapies and prevention.
3. Outpatient before inpatient: what does that mean?
"Outpatient before inpatient" is a regulation of the Federal Office of Public Health (FOPH) that has been in effect in Switzerland since 2019. It states that certain interventions are reimbursed by basic insurance only with outpatient execution, provided no medical reasons speak for a hospital stay. The legal basis is in Annex 1a of the Health Care Benefits Ordinance (KLV).
Examples of affected interventions:
- Varicose vein stripping (surgical removal of varicose veins)
- Arthroscopy of the knee (knee joint mirroring)
- Tonsillotomy without adenoidectomy (partial removal of palatine tonsils)
- Inguinal hernia operations
- Interventions on meniscus and cruciate ligaments
- Certain examinations of the cervix
Background: in Switzerland, many interventions were more frequently performed inpatient than in neighbouring countries, although outpatient treatment would have medically sufficed. The regulation should reduce unnecessary hospital stays and thus also costs.
Important: If there are medical reasons for a hospital stay, for example concomitant illnesses or lack of home care, a cost commitment of the insurer is required. Obtain it before the intervention. Without cost commitment, you bear the difference between outpatient and inpatient reimbursement yourself.
4. When are outpatient interventions and treatments suitable?
Outpatient treatments are suitable for benefits that do not require intensive medical follow-up care. These include smaller health complaints such as flu or cold, routine diagnostics, preventive examinations and medically prescribed therapies such as physiotherapy or speech therapy.
Also smaller or uncomplicated operations are increasingly performed outpatient. The decision between outpatient and inpatient execution is made by the treating doctor on the basis of medical necessity and the FOPH guidelines. For longer interventions, general anaesthetic with observation or with medical concomitant circumstances, a hospital stay is sensible.
Anyone who regularly uses outpatient benefits outside the KVG catalogue, for example complementary medicine, extended therapies or prevention, can secure these via a supplementary insurance. An overview of helpful packages is offered by our article on which supplementary insurance is sensible. Which policy fits in the end depends on your need and your life situation.
Find supplementary insurance for your need
Compando shows which providers best cover your need for complementary medicine, therapies and prevention.
