Tiers garant or tiers payant: who pays the doctor's bill first?

Two billing systems: tiers garant and tiers payant

With tiers garant, you are the first payer: the invoice is sent to you, you pay it and then submit it to your health insurer for reimbursement. This system is usual for outpatient treatment.

With tiers payant, the invoice bypasses you: the provider bills the insurer directly. This is usual in hospitals and pharmacies. It does not make the treatment free — you bear your cost sharing, i.e. the deductible and co-payment, in both systems.

Tiers garant: how to submit the invoice

Submit doctor's bills to your insurer via the app (photo of the invoice), the customer portal or by post. Always keep the original receipts.

Reimbursement is usually made within two to four weeks — minus your cost sharing. If the invoice amount is still within the deductible, little or nothing is paid back accordingly; with every invoice submitted, however, the insurer keeps your deductible balance correctly up to date.

Tiers payant: billed directly — but not free

In hospitals and pharmacies, the invoice usually goes directly to the insurer. The insurer then bills you for your cost sharing — it appears on the cost-sharing statement, which you should keep.

Two points are worth knowing: in hospital, adults also pay a contribution of CHF 15 per day towards the costs of the stay (it does not apply to children or to young adults in education). And for original medicines for which a generic is available, the co-payment can be higher.

What you pay yourself: cost sharing at a glance

Regardless of the billing system, you contribute to the treatment costs of basic insurance:

• Deductible: the amount you pay yourself each year before your insurer takes over — CHF 300 to 2'500 for adults, CHF 0 to 600 for children.
• Co-payment: after that, 10% of further costs, at most CHF 700 per year (children: CHF 350).
• Hospital contribution: CHF 15 per day for adults.
• Maternity exception: from the 13th week of pregnancy until 8 weeks after the birth, no cost sharing is charged for general benefits and nursing care in the event of illness (Art. 64 para. 7 KVG).

Why you should submit every invoice — even below the deductible

It sounds paradoxical to submit an invoice that you pay yourself anyway. Yet it is worth it: this is the only way your deductible balance is recorded correctly and the annual cost-sharing statement is accurate. If you leave invoices lying around, in the worst case you may miss out on reimbursements, because on paper the deductible is used up later than it actually would be.

Accurate billing also matters if you switch insurer during the year: if you switch as of 1 July, for example, the new insurer credits the deductible and co-payment already invoiced in the same calendar year (KVV Art. 103 para. 4) — so cost sharing does not start again from scratch. Keep your previous insurer's cost-sharing statement as proof.

Cost-saving model? First the treatment pathway, then the reimbursement

If you are insured in a family doctor, HMO or telemedicine model, think about the prescribed treatment pathway before treatment. If it is bypassed — for example by going directly to a specialist — you risk the insurer reducing reimbursement or refusing it altogether; you are then left with part or all of the invoice you have already paid. In the case of repeated breaches, the insurer can also order a switch to the standard model. Emergencies are exempt, as are usually gynaecology and eye doctors, depending on the insurer's regulations.

Conclusion: submit, keep, keep track

Whether tiers garant or tiers payant — the system changes nothing about the deductible and co-payment, only the route the invoice takes. And if you have your cost-sharing statements to hand anyway: they are the best basis for reviewing your deductible and model in the autumn — the easyall comparison calculates the options with the official premiums approved by the FOPH.

The most important everyday steps:

• Submit every invoice — via the app, customer portal or by post, even below the deductible.
• Keep original receipts and cost-sharing statements.
• Expect reimbursement usually within two to four weeks, minus cost sharing.
• In a cost-saving model, follow the prescribed treatment pathway — otherwise you risk reductions.