The "Three A Rule": The Right to Remuneration for Private Healthcare Facilities – Commentary on Order No. 16683/2025

In the complex landscape of Italian healthcare law, Order No. 16683 of the Court of Cassation dated June 22, 2025, provides essential clarifications on the prerequisites for the right to remuneration for diagnostic services provided by private entities contracted with the National Health Service (SSN). This ruling, which saw L. and A. in opposition, quashed and remanded a decision by the Court of Appeal of Salerno, reaffirming core principles and introducing the clear "Three A rule."

The "Three A Rule": Indispensable Prerequisites for the Right to Remuneration

The core of Order No. 16683/2025 is the enunciation of the so-called "Three A rule." This principle establishes that the right to remuneration for diagnostic services provided by a private facility depends on the simultaneous existence of three fundamental elements. These are cumulative conditions, the absence of which compromises the right to payment. The Court of Cassation reiterated the public nature of these relationships, which transcends mere contractual logic, anchoring itself firmly in the law.

The right to remuneration for diagnostic services provided by a private healthcare facility arises in the presence of three constitutive prerequisites (the so-called "Three A" rule), which are represented, in addition to the contractual agreement concluded pursuant to Article 8-quinquies of Legislative Decree No. 502 of 1992, by the authorization to carry out healthcare activities and institutional accreditation, respectively provided for by Articles 8-ter and 8-quater of the same legislative decree, so that the source of the right to receive remuneration must be found, rather than on a contractual level, in the law itself.

This maxim is crucial: for the right to payment, a facility must possess the Contractual Agreement (Art. 8-quinquies of Legislative Decree 502/1992), the Authorization to operate (Art. 8-ter), and Institutional Accreditation (Art. 8-quater). The Court highlights that the source of this right is the law itself, not a simple contract. The lack of even one of the "Three A's" prevents the right to remuneration from arising. This is an important warning for all operators in the sector.

• Contractual Agreement: Understanding with the SSN for the provision of services, as provided for by Art. 8-quinquies of Legislative Decree No. 502/1992.
• Authorization to Operate: Administrative permit that allows the facility to operate legally, pursuant to Art. 8-ter of Legislative Decree No. 502/1992.
• Institutional Accreditation: Certification that the facility possesses the requirements to operate on behalf of the SSN, governed by Art. 8-quater of Legislative Decree No. 502/1992.

Conclusions and Practical Implications

Order No. 16683/2025 reinforces the need for scrupulous adherence to the "Three A rule" by private healthcare facilities. This ruling protects both administrative correctness and the management of public funds, as well as the quality of the service offered, ensuring that only facilities fully compliant with legal requirements can access public funds for healthcare services. This establishes a firm point for legality and efficiency in the Italian healthcare system.