How transparent is a Swiss hospital bill really?

Almost CHF67,000 ($82,000) for a stay of around fifteen hours at Sion Hospital. The father of one of the young people injured in the fire in Crans-Montana was very surprised by the size of the bill. Keystone / Jean-Christophe Bott

By law, every patient in Switzerland receives a copy of the healthcare invoices issued in their name. The idea is simple: patients should be able to check the services billed, flag any errors and see what their care costs. But in practice, hospital invoices remain largely unreadable to anyone outside the system.

On April 13, Umberto Marcucci, the father of a teenager injured in the fire that broke out in a Crans-Montana bar on New Year’s Eve, was surprised to receive a hospital invoice of nearly CHF67,000 ($82,000) for his son’s treatment.

Other young people injured in the fire, also treated for a few hours at the same hospital in canton Valais, received copies for around CHF17,000, he says.

The section of Marcucci’s invoice meant to explain the cost contained a single tariff item: a technical description (“complex intensive care treatment…”), a code, a string of numbers and, at the end, the total cost of care.

Documents like this routinely land in Swiss letterboxes. Since 2022, Article 42 of the Federal Health Insurance Act has required healthcare providers to send patients a copy of the invoice submitted to their insurer. The purpose is transparency: patients should be able to check what was billed in their name, report errors and become aware of the costs.

But when Marcucci asked the hospital’s finance department to explain the amount, he received no reply. He also wrote to the then-president of the Valais cantonal government and heard nothing back.

How far can patients really verify a Swiss hospital invoice? And what can they do when they disagree? In a country with one of the world’s highest healthcare spending and steadily rising premiums, this is not a technical detail: patients cannot help contain costs they cannot understand.

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Where the figure comes from

Since 2012, acute hospital stays in Switzerland – as opposed to psychiatric or rehabilitation stays, which use separate systems – have not been billed service by service but with a flat rate per case. There are around 1,070 case groups – categories that bundle together medically similar cases. Assigning a hospital stay to a case group “is an entirely standardised process”, explains in an email Simon Hölzer, CEO of SwissDRG SA, the company that develops the tariffs on behalf of the cantons, insurers and hospitals.

After a patient is discharged from hospital, specialised staff translate diagnoses and procedures into standardised codes. Software then combines them with data such as the patient’s age and assigns the case to a group. Each group has a “cost weight”. Multiplied by the hospital’s base rate – negotiated annually with insurers – it produces the final amount billed to the patient. Hölzer says that because base rates vary from hospital to hospital, “the exact same medical case will cost differently depending on the institution”.

The patient sees only the result: the code, the official description and the multiplication. “For an individual patient, the understanding may be limited,” Hölzer writes. The calculation itself can be easily checked and replicated using the SwissDRG catalogue. The classification cannot: the invoice does not show the detailed diagnoses and procedures that led to the chosen group and code. The omission is deliberate, according to Hölzer. Partly to protect privacy, as “an invoice is an administrative document often handled by non-medical personnel”, and partly because the document is “meant to show the final billing unit, not the granular medical data”.

The bill for a stay in intensive care is very different from that for a stay in a general ward. Keystone / Anthony Anex

Two identical-looking stays can generate different bills for valid reasons: complications that move a case into a more expensive group, additional payments for “high risk/high cost patients, including burns” or intensive-care supplements, Hölzer explains. But these factors are absorbed into the coding and do not appear on the invoice.

Transparent for whom?

“Officially, the aim of the copy is that the patient is able to check if it’s correct,” says Anne-Sylvie Dupont, professor of social insurance law at the Universities of Geneva and Neuchâtel and co-director of the Institute of Health Law. “Less officially, it also shows how much you cost to the system – so that you can feel guilt about it,” as each person’s costs feed into everyone’s premiums.

“For me, a bill is clear, because I know the system very well. But for someone who does not know the system, it’s impossible to understand,” she says. Patients can spot glaring mistakes – heart surgery billed after a broken leg, for example. But deciding whether the correct code was used is “very, very difficult”. When the choice is between two similar codes, she says, verification is “mostly impossible”.

Indeed, invoice questions recur in consultations at the Swiss Patient Organisation (SPO) – an independent non-profit that advises patients on their rights – a spokesperson told Swissinfo. Patients may recognise “the date of treatment, but not the individual tariff positions, the abbreviations, the technical language”.

Patients’ rights and their limits

The first step for anyone who does not understand an invoice is to contact the hospital’s billing department. It can explain how the bill was generated and clarify the coding, SwissDRG says. Patients may also request the detailed coding report and the discharge report.

They can also ask their insurer to review the case, says prio.swiss, the association of Swiss health insurers. Patients can check concrete details such as length of stay, but technical verification “requires specialist expertise”. And the insurers’ own checks usually concern coverage, “formal errors or double billing”, and plausibility based on the data the hospital supplied.

“The system is mostly based on mutual trust,” Dupont confirms. “If you get a bill for an appendectomy, the insurer will not check whether you really had one. They look for patterns, like a hospital with a caesarean rate far above average.”

When doubts remain

“There are very few ways to protest against the bill if your insurer says: okay, thanks for telling us, but we don’t care, we pay the bill anyway,” Dupont points out.

Patients can turn to the health insurance ombudsman, which offers free advice and mediation, but it does not rule. Patients can also demand a formal decision from the insurer and challenge it. For many, the Swiss Patient Organisation (SPO) notes, that threshold is too high: their out-of-pocket share is rarely large enough to justify hiring a lawyer.

Corrections do happen, prio.swiss says, “often discreetly and not always visibly to the insured persons themselves”. Insurers can report a hospital to cantonal authorities, but such cases are hard to see from the outside. “As long as there is no court decision, if you’re not an insider, you don’t know,” Dupont says.

‘Opacity disguised as transparency’

Foreign patients face an additional barrier: they usually have no Swiss insurer to contact. Under EU coordination rules, their own national health system reimburses Switzerland through state-to-state channels, leaving them without an obvious interlocutor. For Marcucci, sending the invoice was “opacity disguised as transparency”.

Canton Valais told Swissinfo that billing “does not fall within the jurisdiction of the canton” and that insurers are primarily responsible for checking invoices. The Hôpital du Valais told Swissinfo the copy “serves solely to inform” patients of the services billed to the insurer and is not accompanied by more detailed information. It declined to discuss the individual case, citing data protection.

Possible improvements

Some small changes could make hospital invoices easier to navigate, Dupont says. Explanations could be printed on the back of the document or published on hospital websites; the Thurgau cantonal hospital, for example, offers a guide to DRG invoices.

Complaint offices, now common in hospitals in French-speaking Switzerland, could also explain bills, she adds, but the administrative cost might outweigh the benefit. “For me it’s pretty clear that the system is not transparent. But I don’t have a better formula to suggest.”

The copy is also supposed to make patients more cost-conscious and help curb healthcare spending. Dupont is sceptical here too. “We’ve seen for 30 years that it doesn’t work.”

Edited by Daniele Mariani. Sub-edited by ts