Medical adviser (Vertrauensarzt)

A medical adviser (Vertrauensarzt or Vertrauensärztin) is a physician appointed by health insurers or their associations. Under the Federal Health Insurance Act (KVG), medical advisers advise the insurer on medical questions and on questions of reimbursement and tariff application; in particular, they check whether the conditions for coverage are met (Art. 57 KVG).

Medical advisers are independent in their judgement: neither the insurers nor the healthcare providers may give them instructions. They pass on to the insurer only the information it needs, for example to decide on coverage or to set the reimbursement (Art. 57 KVG).

Where patients meet it

The role becomes visible in the cost approval procedure. Where basic insurance reimburses a medicine in an individual case under Art. 71a to 71d of the Health Insurance Ordinance (KVV), the insurer decides on the cost approval only after consulting its medical adviser (Art. 71d para. 1 KVV).

• The medical adviser advises; the decision is taken by the insurer (Art. 57 KVG; Art. 71d para. 1 KVV).
• Once the application is complete, the insurer decides within two weeks (Art. 71d para. 3 KVV).
• A refusal must be justified to the treating physician and to the patient (Art. 71d para. 6 KVV).

In German, the service is also called vertrauensärztlicher Dienst. Our article on insurance and cost approval explains the procedure and the role of supplementary insurance.