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Matyas Sagi-Kiss (40) has been going to physiotherapy for two hours a week for over 35 years: “The treatment helps me prevent pain, strengthen my independence and hopefully maintain this in the future.”
Sagi-Kiss has been in a wheelchair since she was young; He was born with cerebral palsy, which is brain damage in early childhood. Symptoms: Arms and legs are affected by spastic paralysis, trunk and head control is impaired.
Despite its limited mobility, Sagi-Kiss has managed to achieve an impressive level of independence. The qualified employment lawyer is president of the disability organization Pro Infirmis Zurich and represents the SP as vice president in the canton’s regional council.
Statement at the neurological competence center
In the summer of 2023, the family doctor ordered the extension of the long-term physiotherapy prescription, as has often happened in recent years. Until now, Sagi-Kiss’s health insurance company, CSS, had always paid for the continuation of therapy, no questions asked. But this time, the CSS “reliable medical service” suddenly questioned the meaning and scope of treatment in order to check the health insurance company’s “obligation to provide assistance”.
Since the CSS was not satisfied with the explanations of Sagi-Kiss’s family doctor, the insured had to go to a neurological competence center in the city of Zurich for an explanation.
Among other things, the health insurance company wanted to find out from independent neurologists what “specific goals” should be pursued in physiotherapy. Those responsible also questioned the “high frequency treatment” and demanded an explanation as to why the frequency could not be reduced.
Health insurance companies are obliged to carry out spot checks
When Sagi-Kiss saw the CSS letter, he thought he was in the wrong movie. “I manage relatively well without doctors, but I couldn’t imagine life without physiotherapy,” she says. That’s why it bothers him that CSS “performance auditors” even bring up the idea of saving money here.
CSS justifies its approach with “legal audit authority”. Accordingly, services within the scope of the Health Insurance Act (KVG) must meet the so-called WZW criteria (effectiveness, suitability, cost-effectiveness).
“KVG insurance is legally obliged to clarify its obligation to provide benefits,” a spokesperson for the company told Blick. Even if there are chronic diseases, WZW criteria should be checked from time to time. “We do not fundamentally question the necessity of physiotherapeutic care for chronic diseases,” the spokesman said. However, it is necessary to carry out on-site checks from time to time.
Sagi-Kiss can’t have much of a thing with this logic. In his opinion, it is clear: “Such control over chronically ill people is unnecessarily burdensome for those affected.” He also points out that the neurologist examination brings additional costs: “My examination cost 600 francs. This is wasted money that will ultimately have to be distributed by premium payers.
Neurologists even recommend four hours a week
The irony of history: the neurologists who commissioned the CSS to review the long-term physiotherapy prescription conclusively confirmed its necessity. Moreover: they even suggested that Sagi-Kiss specified “from a medical and economic perspective” four hours of “high frequency, long-term physiotherapeutic treatment” per week – that is, twice as much as before.
The Physioswiss association filed a supervisory complaint against BAG at the beginning of the year. The complaint is about the new tariff structure. From January 2025, the current flat rates for reimbursement of physiotherapy sessions will be replaced by a tiered system. According to Physioswiss, this would lead to “the destabilizing disruption of a catchment area that is already significantly underfunded.”
The Physioswiss association filed a supervisory complaint against BAG at the beginning of the year. The complaint is about the new tariff structure. From January 2025, the current flat rates for reimbursement of physiotherapy sessions will be replaced by a tiered system. According to Physioswiss, this would lead to “the destabilizing disruption of a catchment area that is already significantly underfunded.”
Against this background, CSS is suddenly preparing to continue taking over its insured’s current treatment. “Our medical trust (…) continues to recommend a frequency of two to three times a week for complex therapy for a further two years,” a spokesman said.
Written cost approval was prepared and sent this week.
Source :Blick
I’m Tim David and I work as an author for 24 Instant News, covering the Market section. With a Bachelor’s Degree in Journalism, my mission is to provide accurate, timely and insightful news coverage that helps our readers stay informed about the latest trends in the market. My writing style is focused on making complex economic topics easy to understand for everyone.
