Hospital cost reimbursement from the sécu

[allanb]

According to what I can find on the CPAM website, the normal reimbursement rate for the expenses of a hospital stay, including surgery, is 80%. I recently had a stay in hospital for a surgical operation for which CPAM paid 100% of the cost, except for the 'forfait hospitalier' of €18 per day and what they call 'frais de confort personnel' (phone, TV, etc).

From the same website, the 100% hospital reimbursement rate is apparently due only in a limited number of cases:

– from day 31 onwards, if the stay lasts that long;

– for pregnancy complications or newborn baby care;

– for accident or illness resulting from professional or work activity;

– for a recognised long-term affliction (ALD);

– following sexual abuse;

– if you are receiving a disability or military pension;

– if you are in the Alsace-Moselle system (I wonder why, but never mind);

– if you qualify for the CMU.

None of these applied in my case. I do have an ALD but it has no connection at all with the surgery I had. And I have a friend who has had exactly the same experience without having an ALD of any kind.

Of course I'm not complaining about getting 100%, but I would like to understand why. Not just to see what I'm missing, but because if this is normal, it would affect the decision whether or not to go on buying supplementary insurance from my mutuelle.

Does anyone have any relevant knowledge or experience?

[Chancer]

All of my stays have been 100% prise en charge except one where I was charged 20%, I never did get to the bottom of it, I was told it was a mistake by the surgeon but she refused to admit it or even talk to me, life can be like that in France and overall it was a small price to pay and I didnt want to risk being charged the 20% on my other stays.

What was galling was that the first surgeon cocked up his procedure, and I was re-admitted a couple of days later to have the exact same operation but that time charged for it, which seems about par for the course in France!!!

[Patf]

I don't think they know what they're doing - there's no logic in it.

In 2006 I had a hip replacement, covered 100% .

Soon after, emergency hospitalisation for a heart attack - 3 days in intensive care, covered 70%.

Unless there are different regs. for intensive care.

[Jay]

[quote user="Patf"]I don't think they know what they're doing - there's no logic in it.

In 2006 I had a hip replacement, covered 100% .

Soon after, emergency hospitalisation for a heart attack - 3 days in intensive care, covered 70%.

Unless there are different regs. for intensive care.

[/quote]

You would have thought that should be the other way around. We had a similar situation, I had a routine walk in/walk out same day operation at 100% but my wife had a five day stay (same clinic), more serious op. at 80%

[NormanH]

I think that the medical staff quite often put things through the system at 100% if you have an ALD even for an unrelated condition. This is wrong, and should be picked up by the CPAM but often isn't.

At one time it was fairly commonplace for an ALD to imply that all treatment was at 100%, but it clearly isn't supposed to be the case now. There remains  among some Doctors a feeling that it still should be and I think if you come across one of them they may  'forget' that you should have to pay a share.

I never understood how Chancer got away with not having to pay part for a colosocopy, as it is only covered at 100% once you have been diagnosed with an ALD such as cancer, not as part of a programme of prevention, but this may be part of the sale syndrome where the medical staff are more 'generous' than than the administrators.

I don't think that you can count on this happening each time though as a couple of posters have shown.

Several people do not have Mutuelles and prefer to put the money aside for if it is ever needed.

This may well make better financial sense, (I have seen well-argued worked examples)  but I think that to have the confidence to do that  you need to have a substantial amount of savings available in case it happens tomorrow before you can build up your 'pot'.

I never had enough to dare to do this, so have always paid a Mutuelle

[Chancer]

I am one of those without a mutuelle and also without significant savings behind me, en bref no choice in the matter.

For those with mutuelles its just a question of curiosity, who pays what and how much but for those without (and without the means) the total non transparence and randomness of the system can cause significant anxiety before treatment and the lack of answers from any quarter means that in many cases people will not go ahead with necessary perhaps essential treatment that may well have been 100% prise en charge anyway.

I know how it felt during a long and at that time indeterminate  period of hospitalisation to recieve a hefty bill for just one of the many and ongoing operations, to realise that I would not be able to pay for the ones that I had already had let alone those to come, no-one could tell me whether I was going to be billed for them or not and indeed some bills, thankfully minor were still coming over 2 years later, which was I was told normale and no they could not tell me if there were or would be any more.

Frankly its a shambles and other government departments aren't any better, it seems to be a case of if we want money from you, when we decide we want it you will pay, point bar [:(]

Norman re me getting away with it, I had another meeting recently with les impôts who have finally taken an interest in me, the lady who is very nice, competent and unusually doesnt mind sharing her knowledge of how things work, how they are calculated and most importantly what options I have said to me very dead-pan, "you do realise that you have been getting away with it for years dont you?"!!

I replied that yes I did now but that it wasnt intentional and worse still I hadnt realised just how much I was getting away with so dint feel any the richer for it!.

Whan she  said "vous avez vraiment eu de la chance!"  I replied "on m'a surnommer Chancer" [:P] 

I know that it doesnt really translate, shame that [:D]

[idun]

Wouldn't 'Chanceux' be OK??????????? Or is my french failing me?????????

[Chancer]

Its the closest but really means lucky rather than someone that chances their arm to become lucky, a gambler on the wheel of fortune that is life.

[sid]

I wonder if there is a list of procedures for which the cost is borne by the state? I can't find it.

I had a cataract (day patient) operation last year and that was 100% covered by the CPAM apart from the obligatory half-day room charge.

 

[allanb]

NormanH wrote: "Several people do not have Mutuelles and prefer to put the money aside for if it is ever needed. This may well make better financial sense, (I have seen well-argued worked examples) but I think that to have the confidence to do that you need to have a substantial amount of savings available in case it happens tomorrow before you can build up your 'pot'."

I agree. It's a difficult decision and it isn't helped by the incomplete or erroneous "information" on the Assurance Maladie website.

For instance, I have been trying to assess the likely cost of a knee replacement, and I went to www.ameli.fr and looked up a surgeon who specialises in that operation and who practises at the hospital where I once had surgery. It appears that the average length of stay for a knee replacement is 900 nights, and the surgeon's normal fee is €99,108 euros (but no worries: the sécu will reimburse €59,108).

I am not making this up and I have not misread any numbers: that is what it says.

Another point is that if Norman is right about staff occasionally choosing 100% when they shouldn't, the ironic thing is that in a case like mine they weren't saving the patient any money. The only people who gained from the 'error' were my mutuelle, who would have had to pay the 20% (or whatever it should have been.)

[NormanH]

You are right that they only saved the Mutuelle money, but that is because you have one.

If you didn't  it would have been you who benefited.

[Cendrillon]

"It appears that the average length of stay for a knee replacement is

900 nights, and the surgeon's normal fee is €99,108 euros (but no

worries: the sécu will reimburse €59,108)."

Surely not 900 nights!!!!![blink]

[Rabbie]

[quote user="Cendrillon"]"It appears that the average length of stay for a knee replacement is 900 nights, and the surgeon's normal fee is €99,108 euros (but no worries: the sécu will reimburse €59,108)."

Surely not 900 nights!!!!![blink]
[/quote]Well it's only about 2.5 years. Seems reasonable to me - not!

[allanb]

NormanH wrote: "You are right that they only saved the Mutuelle money, but that is because you have one. If you didn't it would have been you who benefited."

True; that's why I said "in a case like mine." But it would be a case like mine most of the time, wouldn't it? I think I have read that something like 90% of the population has supplementary cover, so if the practice we're talking about is widespread, the mutuelles are doing very nicely out of it.

[Rabbie]

[quote user="allanb"]NormanH wrote: "You are right that they only saved the Mutuelle money, but that is because you have one. If you didn't it would have been you who benefited." True; that's why I said "in a case like mine." But it would be a case like mine most of the time, wouldn't it? I think I have read that something like 90% of the population has supplementary cover, so if the practice we're talking about is widespread, the mutuelles are doing very nicely out of it.[/quote]Given that the mutuelles are in business to make a profit then if they didn't benefit from this they would just raise their charges to preserve their profit margin so you do benefit a little in the long run.

[woolybanana]

But fewer and fewer French people can afford mutuelles, so maybe don't get treated or pay back slowly.

[NormanH]

I was at the Dentist on Thursday.

While I was waiting the person who had just come out was discussing his bill (for over 400€) with the receptionist, and she treated as quite normal his request that the cheque he gave her shouldn't be presented before the part that was the reimbursement from the Sécu was credited to his account. They reckoned that 15 days gave ample time.

That shows that people are finding it difficult.

[powerdesal]

[quote user="Rabbie"][quote user="allanb"]NormanH wrote: "You are right that they only saved the Mutuelle money, but that is because you have one. If you didn't it would have been you who benefited." True; that's why I said "in a case like mine." But it would be a case like mine most of the time, wouldn't it? I think I have read that something like 90% of the population has supplementary cover, so if the practice we're talking about is widespread, the mutuelles are doing very nicely out of it.[/quote]Given that the mutuelles are in business to make a profit then if they didn't benefit from this they would just raise their charges to preserve their profit margin so you do benefit a little in the long run.[/quote]

I was once told that mutuelles in France were limited in their profit making by French Law, was I mis-informed?

[idun]

As most of our time in France was before the Carte Vitale and speedy reimbursements, it was usual to hand over cheques to Drs or Dentists and them cash them a few weeks later. And sometimes the payment would be made with a couple of cheques, as we had to send off to the CPAM and then when their reimbursement forms came back, then send the lot off to the mutualist to get them to pay that part. It was a very long process and never speedy.

 I don't think that any of that was 'that' long ago that people wouldn't hesitate to use it again?

[Rabbie]

[quote user="powerdesal"][quote user="Rabbie"][quote user="allanb"]NormanH wrote: "You are right that they only saved the Mutuelle money, but that is because you have one. If you didn't it would have been you who benefited." True; that's why I said "in a case like mine." But it would be a case like mine most of the time, wouldn't it? I think I have read that something like 90% of the population has supplementary cover, so if the practice we're talking about is widespread, the mutuelles are doing very nicely out of it.[/quote]Given that the mutuelles are in business to make a profit then if they didn't benefit from this they would just raise their charges to preserve their profit margin so you do benefit a little in the long run.[/quote] I was once told that mutuelles in France were limited in their profit making by French Law, was I mis-informed?[/quote]Which IMO makes it more likely that these savings will be reflected in lower premiums