GP model: what happens if you go straight to a specialist?

GP model and specialists: what the law allows

In the standard model, for outpatient treatment you go directly to any approved specialist who is suitable for your illness (Art. 41 para. 1 of the Federal Health Insurance Act, KVG). In the GP model, you have restricted this right of choice in agreement with the insurer. The insurer then only has to cover the costs of services that are carried out or arranged by the agreed service providers (Art. 41 para. 4 KVG). “Arranged” means: your GP practice has referred you.

That is the core of the model, which experts call gatekeeping. Together with you, the GP practice decides whether a specialist is needed and issues the referral. The statutory compulsory benefits remain insured in every case: the specialist is paid if the route goes through the practice.

In all cases, the normal co-payment applies: the deductible and a 10 % retention fee up to at most CHF 700 a year (Art. 64 para. 2 KVG, Art. 103 para. 2 of the Health Insurance Ordinance, KVV). The insurer can see on every invoice who treated you; the service provider must issue a detailed invoice (Art. 42 para. 3 KVG).

What the rules provide for a breach

The law only says that the insurer does not have to pay. How it deals with a breach is set out by each insurer in its rules. According to the health insurance ombudsperson, the range is as follows:

1. Reminder. For the first, and sometimes also the second, breach, many insurers point it out in writing without immediately refusing the costs.
2. Reduction or refusal. After that, the insurer covers the invoice only partly or not at all.
3. Moving you back. After repeated breaches, it can move you to the standard model, with a free choice of doctor but a considerably higher premium.

The ombudsperson also describes a model in which, for certain specialist fields, the insurer additionally requires contact with an advice service after the referral. Anyone who went to the specialist directly after the referral did not have the invoice paid. In such models, a referral alone is therefore not enough. The article Rules of the cost-saving models summarises the typical rules of all cost-saving models.

Step by step: how to get to a specialist correctly

1. Contact your GP practice first. By phone, by email or with an appointment, depending on the practice. Explain why you need a specialist.
2. Get a referral issued. The practice refers you to a specialist. Ask whether the referral applies to one consultation, a course of treatment or a certain period.
3. Check the rules for additional obligations. For certain specialist fields, some models also require a call to an advice service run by the insurer.
4. Attend the specialist appointment. Mention your insurance model there and bring the referral if you received it in writing.
5. Keep an eye on follow-up appointments. When the referral ends, get a new one before the next appointment.
6. Check your statement of benefits. If the insurer does not pay an invoice, find out why straight away.

Before signing up, check with the model finder whether the model fits your visits to the doctor. The rules of the common models are on the pages about the insurance models.

Exceptions: emergencies, check-ups and specialist fields without a referral

• Emergency. If treatment cannot wait, go straight to hospital or call 144. The rules provide for an exception, but usually require you to inform your GP practice afterwards within a certain period.
• Specialist fields without a referral. Many rules allow certain specialist fields or check-ups without a referral. Which ones differ from tariff to tariff; do not rely on other people’s experience.
• Your GP is away. What to do when your practice is closed, for example via a stand-in or a telephone advice service, is set out in the rules.
• Ongoing treatment when switching to the model. If you are already being treated by a specialist, clarify with the GP practice and the insurer before switching how the referral for further treatment will be handled.

What the GP model saves in 2026

Premiums 2026, municipality of Basel (region 1), adults (born 1988), with accident cover; source FOPH. The tariffs in the GP/HMO category also include HMO and pharmacy tariffs.

For the last column, we compared each insurer’s cheapest GP or HMO offer with its own standard model. Depending on the insurer, the discount in Basel in 2026 was between 3.4 % and 22.5 % (deductible CHF 2,500). The premium calculator shows the premiums for your municipality.

Sample calculation: a refused invoice and the deductible

Example with fictitious people. Anna is 38, lives in Basel, has a deductible of CHF 2,500 and is insured in the GP model. In February, she goes straight to a specialist without a referral; the invoice comes to an assumed CHF 600. The insurer refuses it under its rules. In the autumn, she has treatment with a referral, an assumed CHF 3,000.

With a low deductible that has already been used up, the difference is even greater: you then pay only 10 % of a covered invoice, but 100 % of a refused one.

If the insurer refuses the specialist’s invoice

If you disagree with the refusal, for example because you claim an emergency or a valid referral, ask for a written decision. The insurer is obliged to issue one if you disagree with its decision on a benefit (Art. 49 para. 1 of the Federal Act on the General Part of Social Insurance Law, ATSG). You can lodge an objection to the decision within 30 days (Art. 52 para. 1 ATSG). The health insurance ombudsperson advises you free of charge. The article Benefit refused describes the process. We cannot judge whether there was an emergency in your case.

Leaving the GP model

If the model does not suit your visits to the doctor, you can leave it at the end of the year. Your notification must reach the insurer by 30 November; from 1 January, you are in the standard model or in another model (Art. 100 para. 3 KVV, FOPH). Switching from the GP model to the telemedicine model is also only possible on this date. Conversely, you can switch from the standard model to a GP model at any time (Art. 100 para. 2 KVV). Which models there are and what they cost is shown in the article GP, HMO, Telmed, pharmacy.

Common mistakes

• Continuing treatment with an old referral. Referrals are often limited to one treatment or a certain period. Ask before follow-up appointments.
• Not telling the specialist about your model. Then the practice does not know that it has to pay attention to the referral for follow-up appointments or further referrals.
• Assuming your GP knows the additional obligations of your tariff. According to the ombudsperson, GPs generally do not know the conditions of the individual models in detail.
• Adopting exceptions from acquaintances. Which specialist fields you can see without a referral is different in every tariff.
• Simply paying a refused invoice without asking. If you can prove an emergency or a referral, ask for a written decision.

The article Telemedicine model explains how the model with a phone call instead of a GP practice works. You will find all topics on saving money in the section Saving money; the profiles of the insurers with their models are under Health insurers.