Payment denied: Health insurance company slows down psychiatric care

What you need to know is that if a nurse explains which psychiatric measures should be covered by the health insurance company after a doctor’s recommendation, she must be able to prove that she has two years of professional experience, like Nadège Tebiro. Health insurance companies need to check this.

For years this was done by a joint commission of the health insurance association Santésuisse, Spitex Switzerland and the professional association of Swiss nursing professionals (SBK). At the end of 2021, the agreement was terminated due to Santésuisse unilaterally tightening the conditions; Spitex and SBK are complaining. A separate office called BEPSY now conducts the admission test.

The patient’s Spitex was removed

There has been wild growth since then. Nadège Tebiro has been caring for a client who has been suffering from schizophrenic attacks since December 2022. The insurance company EGK only requested approval for the needs assessment in June 2023. Tebiro presented his evidence according to the old agreement, which was no longer sufficient. Now he must pass the BEPSY verification procedure, pay 400 francs and wait until the next exam date in November.

Another result: Tebiro’s client’s Spitex appointments were canceled mid-treatment. Now he must either look for a new BEPSY-approved Spitex buddy or wait until November. Tebiro intervened against EGK but so far without success: “He is trying for me, but he is irresponsible towards my client.”

Nadège Tebiro is not alone in her anger. This is confirmed by Pierre-André Wagner, head of legal services at SBK: “Instances where health insurance companies put the brakes on psychiatric care are increasing.”

The clerk believes treatment is unnecessary

Another case involved a young student with mental health problems who was referred to a nursing specialist by his family doctor. Nadège Tebiro started treatment. Then it started: First, his professional certificate was rejected by the KPT health insurance company, but then, after a while, it was accepted. The next hurdle was the insurance company’s performance review. It was also announced that therapy costs would no longer be covered until the review was completed, regardless of the client’s health condition.

When the mentally ill student contacted KPT, he was brushed off by a clerk. In his opinion, psychiatric Spitex support was unnecessary. Things got worse: Transfer of benefits was retroactively refused on the grounds that there was a lack of “sufficient expert medical assessment”. The family doctor’s report is not sufficient. In addition, the patient neither receives psychotherapeutic treatment nor uses medication. Translated, this means: If you are not using any psychotropic drugs, you do not need a psychiatric hospital.

Nadège Tebiro has spent 30 hours on her client so far. Will this service not be paid for? He wants to fight: “No interest can be canceled retroactively. “I will defend myself in court if necessary,” he said. He or she may lodge a complaint with the responsible cantonal court or may first appeal to an arbitral tribunal, which includes a representative of nursing professionals.

From the perspective of the professional association SBK and Spitex Switzerland, the licensing conditions for psychiatric care of many health insurance companies are illegal. What Santésuisse denies: The BEPSY office is a service that is not legally binding. If a request is denied, the service provider may request an appealable order.

Federal Office does not respond to complaint

Spitex Switzerland had a report prepared by Professor Ueli Kieser, a well-known social insurance expert. According to the regulations of the Health Insurance Law, a cantonal nursing specialist license plus two years of study in the field of psychiatry is required to practice the profession. According to Kieser, health insurers cannot unilaterally request additional conditions. However, BEPSY excludes activities below 50 percent for proof of professional experience abroad as well as practical experience, among other things.

Therefore, Spitex Switzerland, the association of private Spitex companies and the professional association SBK Curacasa filed a supervisory complaint with the Federal Office of Public Health. However, the office did not take action on this issue. Reason: The umbrella organization Santésuisse is not an insurance company and therefore does not fall under the supervision of the Federal Office. And ultimately only the court can decide whether the approval requirements have been met. More is coming.