The term gatekeeper has become widely used in the health insurance industry to define a first stop for medical advice. When you use a “managed care” cost-cutting model, the gatekeeper is responsible for performing an initial examination or consultation before referring you to specialists or hospitals.

In the Swiss family doctor insurance model, a specific, predefined doctor acts as the gatekeeper. An HMO health center acts as the gatekeeper in the HMO model, while the qualified staff at a predefined pharmacy act as the gatekeepers for pharmacy-model policy holders. The telemedicine model uses qualified phone representatives as gatekeepers.

Important: If you have a low-cost policy but visit a specialist or hospital directly without consulting your gatekeeper first, your health insurance provider will not cover resulting healthcare costs. Exceptions to this rule include medical emergencies and treatment by pediatricians, gynecologists, eye doctors and dentists, which can normally be consulted directly.

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Expert Benjamin Manz
Benjamin Manz is CEO of and an independent expert on banking and finance.