Notes · Private clinics
The day the insurance stopped paying, your patient was already talking to someone else.
When an insurer and a clinic cannot agree, a stay in a private or semi-private ward is no longer covered. What the insurers themselves explain, how long it usually lasts, and why a clinic should have its answer ready in advance.
Picture this: on a Monday in March, the front desk of your clinic in Geneva takes the fourth call of the morning. A patient with semi-private cover was due to have a hip replacement on the 14th. Her insurer has just told her that, for now, it will not cover a stay at your clinic. And it has offered to help her find another one.
That is not an exaggeration. It is what one of the large Swiss insurers explains in writing on its website: if a hospital has not signed a contract with it, it will not pay for an inpatient stay in a private or semi-private ward under supplementary hospital insurance, and it offers to find, together with the customer, an equivalent hospital nearby where the costs are covered.
Not an isolated case.
Following the requirements FINMA published in 2020, the Swiss Insurance Association drew up an industry framework in 2021 with eleven principles for describing and billing supplementary services, and insurers renegotiated their contracts. Helsana, for example, says it terminated every contract that did not meet those principles. Not every negotiation ended in time.
In spring 2024, CSS stopped issuing payment guarantees for the private and semi-private wards of five clinics belonging to a large private group in Zurich, Geneva and Lausanne, until an agreement restored access from 1 May. During those weeks it did not cover the additional services of the stay, although it kept paying the doctors’ additional fees, and it set up a task force to find solutions for those affected and show them alternatives. By then it had renegotiated 123 of its 160 contracts. Helsana, for its part, had not reached agreements in Geneva and Vaud when the transition period ended on 1 January 2025, and its customers faced restrictions there until the agreement it announced on 23 June.
Helsana sums up how long such a situation usually lasts: in its experience, between two and six months, and longer in rare instances. And it puts it plainly: the insurance company annoys the customers affected, and the hospital loses important income.
Who talks to your patient.
What matters in those months is not the tariff. It is who holds the conversation. According to its website, the insurer proactively informs its customers depending on the hospital’s size and importance, advises them and suggests other hospitals nearby. Anyone who already has a payment guarantee for their procedure is not affected. In an emergency, every hospital must provide care, and a stay in the emergency department or the general ward is covered by basic insurance.
So that morning, your patient receives clear information from her insurer. The question is what she receives from you. A row of insurers’ logos on the website does not answer what she wants to know: whether she is covered, since when, what it would cost her and what she can do.
When there is no contract, someone else holds the conversation with your patient.
Where I stand.
A clinic cannot control whether a tariff negotiation fails. It can control what the patient finds when she looks it up that morning, and what she is told on the phone. I would prepare it the way you prepare an emergency plan: before you need it, approved by management and ready to switch on the same day. Management conducts the negotiation. The patient’s trust is won or lost at the front desk.
What I would check.
- A page ready to publish. Which insurer, which products and which wards are affected, since when, what remains covered and how each patient can check their situation.
- A script for the front desk. Whether the patient already has a payment guarantee, which policy exactly, and what real options she has, from waiting to paying the difference.
- The list of scheduled procedures. Patients in the coming weeks whose payment guarantee has not yet been issued.
- Prepared messages. A personal notice, in each patient’s language, sent the same day and not a week later.
- Your dependence. What share of private and semi-private revenue comes from each insurer.
Before the next renegotiation.
- This month
Measure your dependence
Work out each insurer’s weight in the private and semi-private wards.
- This quarter
Write the page and the script
With management and the legal department, without publishing them yet.
- Before each renegotiation
Review pending guarantees
Know which patients would be exposed if there is no agreement.
- On the day
Switch it all on
Publish the page, send the messages and give the front desk the same information the insurer has.
Imagine that on Monday an insurer stops covering semi-private care at your clinic. At a quarter past nine the phone rings. It is a patient who had surgery a month ago, asking whether her follow-up is still covered.
Who answers? With what words? And what does that patient find if, instead of calling, she looks for the answer on your website? If her first explanation comes from her insurer, the second call may no longer be to you.
If you would like me to review what a patient would find on your website and on your phone line today if an insurer stopped covering her tomorrow, start with the Strategic Diagnostic. What can be said publicly about an ongoing negotiation is for your legal adviser to decide, not a designer.