8. October 2024 – In its decision of 8 October 2024, the Federal Supreme Court dismissed the appeal of a physician against the ruling of the Arbitration Court for Social Insurance Disputes (Schiedsgericht nach den Bestimmungen des eidg. Sozialversicherungsrechts) of the Canton of Lucerne regarding the repayment of CHF 284,790 for alleged excessive billing practices under the compulsory health insurance (obligatorische Krankenpflegeversicherung, OKP) for the years 2012 and 2013.

The court noted that the appellant, as a service provider, was obliged to issue invoices only for services that were economical, appropriate, and necessary. The Cantonal Arbitration Court had conducted a comparative analysis using the average cost comparison method (Durchschnittskostenvergleich) based on the billing statistics, which lead to the conclusion that the physician's practice was economically unsound, characterized by excessive billing. The court confirmed that the average billing data, despite the appellant’s objections regarding its reliability, had been upheld as valid in previous rulings, affirming that the statistical method applied was appropriate for assessing economic efficiency.

The appellant argued that the sanctions imposed, in particular the full repayment of the fees for the allegedly inappropriate services, violated the principles of good faith and proportionality. The court clarified that, although repayment constitutes an administrative disadvantage aimed at reclaiming unlawfully obtained benefits, it is not inherently disproportionate to require full repayment upon the first determination of an economic inefficiency. Additionally, the appellant’s claims regarding the absence of prior repayment demands were insufficient to establish an expectation of compliance with the economic viability requirements of service delivery. In this regard, the court also ruled that the appellant’s right to be heard was not violated, as the Cantonal Arbitration Court had made its decision based on the existing evidence, concluding that there was no need for further evidence.

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