NHS refusing to pay for treatment in France

[Chancer]

I cant see the relevance either.

The EHIC gives you the same rights to healthcare as a citizen of the EU country where you recieve the care.

100% of French citizens do not get private rooms unless they pay for them, the SECU will not re-imburse this, ergo a UK citizen using his/her EHIC card in France will have to pay the supplement for a private room and the NHS will not refund it.

I dont think any rights to health care in ones country of residence/domicile have any bearing on the use of the EHIC in other EU countries, however perhaps the NHS gives these 50% of private rooms to foreigners holding CEAM's, a Daily Mail story in the making if so!!

[nomoss]

[quote user="NormanH"]KathyF said that her Googling showed that private clinics are not reimbursed by the EHIC.

I still maintain that I don't know any private clinics in the English sense, but if CeeJay has been refused it seems that the sort of 'clinique' that we have here, privately funded, but re-imbursed by the Sécu, may have been considered as a 'private'  one by the NHS.

Some quotations: The card gives access to reduced-cost or free medical treatment from state healthcare providers.
It will not cover any private medical healthcare.
you should be able to get the same treatment as a resident of the country you're visiting.

http://www.nhs.uk/NHSEngland/Healthcareabroad/EHIC/Pages/Introduction.aspx

This is where the possibility of confusion arises, if someone from the NHS  in the UK interprets a 'clinique' as being private in the UK sense.
[/quote]

 

If the clinic used is one for which CPAM refunds the costs (or part of these) for a person in the state system, doesn't that make them a state healthcare provider?

 

[NormanH]

I agree nomoss.

What I have suggested, among other things is that someone in the NHS dealing with CeeJay's file may not see it like that..

"This is where the possibility of confusion arises, if someone from the

NHS  in the UK interprets a 'clinique' as being private in the UK sense."

[idun]

I have just got to the bottom of this. Seven phone calls was what it took and speaking to a manager in Newcastle.

 

In theory the NHS does not pay out if a private clinique is used in France, they are the rules. However, IF the private clinic accepts the EHIC then they will bill the NHS overseas healthcare team with the bill for the same percentage of the treatment as they would bill the Secu in France. The rest is down to the patient to pay and this can be a lot.

I have called two clinics I know of in France and they are happy to put the EHIC's through their books and I can only assume that in some way they are conventionne by the french health authorities in order to do this.

 

Ceejay, why you didn't have travel insurance I have no idea. The bill you have is your part of the bill, the NHS should have been billed with the rest. IF the clinic haven't billed the NHS, then it is all down to you, as you went to a clinic that couldn't bill the NHS, in truth they  should have let you know at the time and maybe you could have gone to a state hospital instead.

 

[NormanH]

In theory the NHS does not pay out if a private clinique is used in

France, they are the rules. However, IF the private clinic accepts the

EHIC then they will bill the NHS overseas healthcare team with the bill

for the same percentage of the treatment as they would bill the Secu in

France. The rest is down to the patient to pay and this can be a lot.

These are the charges I was detailing in a previous post as part of the explanation

I have called two clinics I know of in France and they are happy to

put the EHIC's through their books and I can only assume that in some

way they are conventionne by the french health authorities in order to

do this.

This is what I keep trying to explain...the fact that an apperently 'private' clinique in France is in the large majority of cases conventionné, and so reimbursed by the Sécu (and so should be by the NHS)

There are almost no' private' cliniques in France 

From the ameli website:

Les cliniques privées non conventionnées

Les cliniques

privées non conventionnées sont très peu nombreuses en France.

Néanmoins, si vous choisissez ce type d'établissement, vous devez régler

la totalité des frais à la clinique.

http://www.ameli.fr/assures/soins-et-remboursements/combien-serez-vous-rembourse/hospitalisation/frais-d-8217-hospitalisation-et-remboursement.php

[Chancer]

In my book being conventionné means no depassement des honaraires yet some of the specialists at my surgery do, the audiologist or whatever they are called and I believe so do some surgeons in the state hospitals, so can you have a clinique conventionée with a surgeon who depasses (sorry!) les honoraires?

I made a point of asking my surgeon and the anaethshetist and they both assured me they were conventionné so I am probably muddling the terms.

I am pretty sure that everyone in the eye hospital was conventionné, it was a teaching hospital, Norman has already recommended these, to be honest its a bit of a minefield for a resident immigrant, lord knows how people got on before the t'internet, not surprising really that a holidaymaker could get caught out.

[NormanH]

Another point about teaching hospitals is that the staff are usually salaried, and have posts such as 'Professeur'

You are mixing up Conventionné Secteur 1 with Conventionné Secteur2,

Both are reimbursed, but Secteur 1 Doctors have accepted the tariff de base, while the Secteur2 are free to charge what they like.

and the Doctor with the establishment

So a clinique can be conventionné, (that is to say the Sécu has accepted to reimburse at least some of the cost)  but some of the Doctors may be secteur 2

I believe, but am a bit shaky about this,  that even Secteur 1 Doctors can charge 'dépassement d'horaires ' ( a home visit from your GP for  example)

Le médecin conventionné de secteur 1 applique le tarif conventionnel.

Un dépassement d'honoraires n'est autorisé qu'en cas d'une demande

particulière de votre part, comme par exemple une visite en dehors des

heures habituelles d'ouverture du cabinet de votre médecin. Ces

dépassements ne sont pas remboursés par l'Assurance Maladie, que vous

soyez dans le cadre du parcours de soins coordonnés ou non.

Le médecin conventionné de secteur 2 pratique des honoraires libres.

Il

est en effet autorisé à pratiquer des dépassements d'honoraires avec

tact et mesure. Le montant du dépassement n'est pas remboursé par

l'Assurance Maladie.

Dans le cadre du parcours de soins, la prise en charge par l'Assurance Maladie est de 70 % du tarif conventionnel.

[NormanH]

You are mixing up Conventionné Secteur 1 with Conventionné Secteur2

Both are reimbursed, but Secteur 1 Doctors have accepted the tariff de base, while the Secteur2 are free to charge what they like.

So a clinique can be conventionné, but some of the Doctors may be secteur 2

I believe, but am a bit shaky about this,  that even Secteur 1 Doctors can charge 'dépassement d'horaires ' ( a home visit from your GP for  example)

Le médecin conventionné de secteur 1 applique le tarif conventionnel.

Un dépassement d'honoraires n'est autorisé qu'en cas d'une demande

particulière de votre part, comme par exemple une visite en dehors des

heures habituelles d'ouverture du cabinet de votre médecin. Ces

dépassements ne sont pas remboursés par l'Assurance Maladie, que vous

soyez dans le cadre du parcours de soins coordonnés ou non.

Le médecin conventionné de secteur 2 pratique des honoraires libres.

Il

est en effet autorisé à pratiquer des dépassements d'honoraires avec

tact et mesure. Le montant du dépassement n'est pas remboursé par

l'Assurance Maladie.

Dans le cadre du parcours de soins, la prise en charge par l'Assurance Maladie est de 70 % du tarif conventionnel.

Spécialiste - secteur 1 - ou secteur 2 avec option de coordination	46 €	46 €	70 %	31,20 €
Spécialiste secteur 2	honoraires libres	46 €	70 %	31,20 €
Psychiatre Neuropsychiatre Neurologue - secteur 1 - ou secteur 2 avec option de coordination	57,50 €	57,50 €	70 %	39,25 €
Psychiatre Neuropsychiatre Neurologue secteur 2	honoraires libres	57,50 €	70 %	39,25 €

[CeeJay]

Thanks for all the replies, my head is now spinning!!

I am awaiting a phone call from Newcastle from the person who made the judgement so maybe all will be revealed.........maybe!

Idun, thanks for your efforts in making those enquiries, I do appreciate it but please, please don't keep asking why I didn't get travel insurance........I didn't, so nothing changes!!

The actual invoice for the treatment included everything, and yes there was a private room, apparantly the Clinique billed CPAM for the amount and CPAM refused to pay as I was not in receipt of a Cartle Vitale, so the Clinique has billed me!! What the conventional system is/was I have no idea and my French is not up to much to have an argument with them.

My point of contention, as I have stated before, is not what is in the invoice but the fact that any costs are not reimbursable through a Clinique!

[Chancer]

Ok I think that I may be able to throw some light on this, I am making the assumption that like most holidaymakers or second home owners you will not have presented yourself at the CPAM with your EHIC and French bank RIB (assuming you have one).

Had you done so (not a criticism [:)]) then you would have been issued with a numéro de sécurité sociale and once in posession of this the clinic would have been able to claim from and be paid direct by the CPAM and you would in turn have been billed the 30 or 20% that remained at your charge together with the private room, forfait journalier etc.

Smaller expenses like doctors visits, prescription medication etc you would normally pay up front and then send off the feuille de soins to the CPAM who would repay you the 70% less one Euro direct to your bank account.

It seems that you will have to prove to the NHS that a French national would have been prise en charge at the clinic for the same treatment, I dont want to ask why you were treated but if it was considered emergency treatment then normally you would be 100% reimbursed, were it for breast augmentation probably nothing [;-)]

[NormanH]

[quote user="CeeJay"]Thanks for all the replies, my head is now spinning!!

I am awaiting a phone call from Newcastle from the person who made the judgement so maybe all will be revealed.........maybe!

Idun, thanks for your efforts in making those enquiries, I do appreciate it but please, please don't keep asking why I didn't get travel insurance........I didn't, so nothing changes!!

The actual invoice for the treatment included everything, and yes there was a private room, apparantly the Clinique billed CPAM for the amount and CPAM refused to pay as I was not in receipt of a Cartle Vitale, so the Clinique has billed me!! What the conventional system is/was I have no idea and my French is not up to much to have an argument with them.

My point of contention, as I have stated before, is not what is in the invoice but the fact that any costs are not reimbursable through a Clinique!

[/quote]

And my point is that there are 2 parts to costs.

1) is payable by everybody, French or English (private room etc)

2) the medical side which should be reimbursable through a clinique. I feel that somebody at Newcastle might have misunderstood what a clinique is.  As I have pointed out it is not private in the UK sense of the term.

[idun]

Ceejay, if you had handed your EHIC in and they took a copy, IF this place was conventionné then they would have got the money they were due from the NHS, whether that would have been via the CPAM, I do not know. If it wasn't conventionné then you are on a loser completely.

And frankly we still do not know if this was the extras that the mutualist would usually have picked up, if you have made that clear already, then I've missed it somewhere along the line, so my apologies. And if it was the extras, then it will still be up to you.

Why don't you call your CPAM and ask if this clinique was conventionné or call the clinique themselves, the bureau des admissions will be able to tell you immediately if they are and if they accept EHIC's.

And the insurance, well a warning to me not to forget it as well as every body else really.

[idun]

I forgot to say that I have emailed Newcastle and told them that most private french clinics  are conventionné and explained that there are few truly private clinics.

[NormanH]

A very helpful and civic thing to do idun.

[idun]

Here is some more information from this website:

http://goo.gl/rBn2z

 

 

Treatment,coverage and costs

Before making an appointment with a doctor or dentist make sure that they are registered with the state healthcare provider in France (conventionné ie). ‘Conventionné’ practitioners can fall into either of the following two categories:

• Secteur 1: practitioners who charge the official social security rate or
• Secteur 2: practitioners who charge an extra fee on top of the official rate

Doctors

You must pay the doctor directly. The doctor then will fill out a treatment form (feuille de soins) and a prescription if necessary. The treatment form is necessary  to claim any refunds. You can claim back around 70% of the standard treatment cost. The standard rate for a consultation with a general practitioner is 21 Euros and 25 Euros for a consultation with a specialist. These charges are non-refundable in France but you may be able to seek reimbursement when you are back in the UK.

Dentists

You must pay the dentists direct who will then fill out a treatment form (feuille de soins) and a prescription if necessary. The form is necessary to claim any refunds. You can claim back around 70% of the standard treatment cost. This is non-refundable in France but you may be able to seek reimbursement when you are back in the UK.

Hospital treatment

If you are admitted to hospital, make sure you present your EHIC or your ‘carte vitale’ on admission. This will save you from paying any refundable costs up front and ensure you only pay the patient contribution.

Generally, you will only have to pay a 20% co-payment towards your treatment, sometimes it will be free. Inpatients will have to pay a daily hospital charge of 16 Euros. If you are admitted to hospital and receive any major medical treatment, you will be charged a flat-rate contribution of €18 in addition to the daily hospital charge or the 20% co-payment. These charges are non-refundable in France but you may be able to seek reimbursement when you are back in the UK.

If you are admitted to a private hospital or clinic, try to ensure that it is also registered to provide state healthcare.

Prescriptions

You should choose a pharmacy that is working within the French healthcare system. With your prescription, you should receive a treatment form (feuille de soins) – you cannot claim a refund without it. 

Prescribed medicines are only reimbursable if they are listed as reimbursable pharmaceutical products. Reimbursement rates vary between 15% and 100 % of the sale price.
This is non-refundable in France but you may be able to seek reimbursement when you are back in the UK.

For more information on which medicines you can claim back contact CLEISS. 

Ambulance

In France, a doctor has to confirm that you are really in need of an ambulance service. Alternatively, you could use a light medical vehicle (vehicule sanitaire leger - VSL) to get to hospital.

Ambulance charges are due if you are being admitted or discharged from hospital. This is non-refundable in France but you may be able to seek reimbursement when you are back in the UK.

Air Ambulance

The availability of air ambulance services varies and depends on the nature of the emergency.

 

As the NHS obviously understand the notion of ‘conventionné’, with regards to Doctors, who after all are ‘private’ as they work for themselves, they simply have a contract with the french health authorities. Then the same argument can be made for the clinique privé who are also conventionné. And an argument that I would hope that anyone being refused reimbursement from a clinique privé conventionné will use.

Please note, it does say that if an EHIC is shown, any bill will be for the rest of the things that are not covered by the french health service.

 

 

[powerdesal]

Hospital treatment

If you are admitted to hospital, make sure you present your EHIC or your ‘carte vitale’ on admission. This will save you from paying any refundable costs up front and ensure you only pay the patient contribution.

It didn't work that way for us.

SWMBO spent 6 days in Avranche Hospital after admittance from Urgence who had taken a copy of her EHIC. We got the full bill, paid it and sent the documents and claim form to Newcastle. The repayment was made directly to our account.

[idun]

I remember powerdesal, but it shouldn't work like that. The person I spoke to in Newcastle said that the 'norm' was for the NHS to be billed for the reimbursed parts of the hospital bill.

So how much did you get back then?

[powerdesal]

We got all of it bar the E18 per day.

[CeeJay]

Thanks once again for all the contributions to this thread.

After about 2 weeks trying to speak to someone who makes decisions at the Overseas Health Care Team I have this morning received a call from a claims manager who apologised and informed me that the original decision of refusal because the Clinique was private was wrong and that the claim would be paid in full!!!!!

I enquired as to how the original decision was made and I was informed that because of the many claims they get from many countries with differing situations their hi-tech answer is to go on the internet and check out the hospital concerned. Apparantly, this particular claims advisor saw that the clinique I used was a private one and came to the wrong conclusion. The manager I spoke to made further enquiry and determined that the clinique was conventionee and therefore the claim would  be approved.

I am not totally convinced that is what actually happened, rather an excuse for a mistake made, as surely a government department would, or should, have a list of, at least, major countries and have details of their systems, however, good conclusion!!!!

[NormanH]

Very pleased for you[B]

It is what I suggested a few posts back...

"2) the medical side which should be reimbursable through a clinique. I feel that somebody at Newcastle might have misunderstood what a clinique is.  As I have pointed out it is not private in the UK sense of the term".

[woolybanana]

I am at the stage of waiting for Newcastle to issue my EHIC when they receive the relevant paperwork from France and have processed my application form which they will only issue when the French have done their bit. So, I asked them what to do if I needed to travel in the meantime. The reply was to take their fone number with me and get the hospital giving treatment to contact them and they would send a fax confirming that I had an EHIC in the pipeline, so the paperwork wopuld go direct to them and the bills too.

Somehow I am not reassured by this!

 

[idun]

Be reassured WB, that is how it works and will work.

 

[CeeJay]

An update on the situation is that I received a phone call this morning from the Overseas Health Care Team, who informed me that they had now written to the Clinique concerned to find out if they were in fact a purely private clinique and if not what should be the level of reimbursement in my particular case.

I cannot believe that they will go to these lengths with every claim from France, or anywhere else for that matter, surely there are set procedures with intimate knowledge of each individual country, they are, after all, a Government Dpt?????

[idun]

During my never ending calls to Newcastle I do ask about cases such as yours CeeJay and generally how these things work.

If the clinique had given you paperwork that appeared like all the other forms Newcastle recieves, it should have gone through without being queried. I do hope that your clinique is conventionné.

This is the copy of a letter I got from Newcastle when I asked about reimbursements.

 

I can confirm that if you were to be treat as a French National you would still have to pay a patients share of the cost of medical care.

If a hospital or doctor accepts an EHIC you would generally have to pay a patients share of the costs and you could then apply for a refund of the amount to us, however this is sometimes free.

If you were not billed at the time of the treatment it is possible that they could send a bill on to you which you could settle and then apply for a refund to us. Alternatively we can issue a provisional replacement certificate to authorise the local insurance office to settle the bill, which may result in a reduced bill being sent to you. This would then have to be settled and then you could apply for a refund to us.

I hope this is of some help.

Yours sincerely,

 

ps I'm hoping that one day soon, the secu in France will get their act together and I won't need to call Newcastle for ages......... I really do.

 

[CeeJay]

Idun

Your continuing replies are a great help and I do admire your tenacity.