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Confused!! and worried!


maude

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Mon ami has recently had hospitalistion for keyhole surgery to the shoulder and vertebrae.

On leaving hospital after 4 days ,300e was demanded as payment for surgery.His top up mutuelle will not pay this as it is deemed to be the discrepancy between what the State pays and the surgeons latest payment demand.I was told this was a new "alteration" to the system brought about by surgeons wanting a bigger payment and the government passing these onto the punters.

Can someone re explain this in words of simple meanings!If true will vacate this place irrespective of any losses.Already food bills are stronomic without worrying additionally. Maude
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This, I am rather guessing I admit, is a graphic illustration of the difference between the percentages on top-up policies.  If yours is a 100% policy only then it will pay only the amount which the state deems appropriate for a specific treatment.  If your surgeon charges more then yes, you are liable to pay the difference.  If you have a 200% policy it will pay up to twice the state amount; a 300% policy three times, and so on.  You must decide whether to bump up your policy (and pay more per month) or risk these kinds of charges in the future. 

Edit : When I first came here six years ago, my insurance company only offered 100,200 and 300 policies.  Now it offers 400% in addition.  That tells me something!

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The overcharging is called un dépassement d'honoraires and are much less likely to be found in clinics and hospitals in les petites agglomérations than in larger towns and citys like Clermont-Ferrand, Lille, Lyon or Orléans where they are quasi systématique.

Some examples:

49% of cataract operations have dépassements between €38 and €1250

57% of hernia operations, between €46 and €1298

69% of hip replacement operations, between €101 and €1720

62% of carpal tunnel surgery, between €49 and €542

Figures from Le Particulier.

I would say Maude that your friend got off quite likely, one should always ask for confirmation before any treatment that it will be carried out at the tarif de convention de l'acte especially if you do not have a mutuelle.

There is new legislation being enacted where surgeons can opt for a new sector called optionelle whereby they will facture at least 30% of their acts at the terif de convention and limit thei depassements to 50% of the tariff for the remaining operations but this will not be for at leat another year.

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As I have explained before ( and Chancer's figures provide a good

example) there are two catagories of Doctor.

Secteur 1 and Secteur 2

1) A secteur I Doctor will charge the official tariff for the

consultation or operation or whatever, and you are then partially

reimbursed by the Sécurité Sociale, and  topped up to 100% of that

official tariff
by your Mutuelle if you have one, with perhaps a euro

taken off as a 'forfeit'

So a consultation with a specialist has a tariff of 44 euros, you will

be reimbursed about 28 euros by the Sécu and 15 by the Mutuelle giving

you 43 euros.

2) A secteur 2 Doctor can charge anything (it's called 'libre', but that

doesn't mean 'free' it means they are free to charge what they like)

The Sécurité Sociale will still only reimburse at the standard tariff

though, so if your specialist decides to charge 66 euros you will still

only get back the 28 from the Sécu.

Whether or not your Mutuelle will make up the difference depends on the policy you have.

If you have 100% cover they will make up the difference to 100% of the

official Tariff (in this case 44 euros) leaving you to find the extra

22 (+I euro 'forfeit')

If you have 150% cover the Mutuelle will meet the difference up to 150%

of the tariff..(in this case  44x150%=66 euros), so there would only be

the 1 euro 'forfeit' to pay

The same distinction applies to anaesthetists so you may find that not

only do you have to pay extra for the surgeon, but also for the

anaesthetist

For the two together this can easily mount up to 300 euros and far

more, especially of your Mutuelle only covers up to 100%, or your

Doctor is particularly expensive

Secteur 1 Doctors are still common among GPs and in the public

Hospitals. The best are to be found in large CHU (teaching hospitals)

Secteur 2 Doctors and anaesthetists work in their own surgeries and in

the Private Cliniques, which exist to make a profit for the private

money which paid for them.

In some cases these Cliniques make a point of doing as many tests and

procedures as they can in order to make money on them, and  this of

course increases the debt of the Sécurité Sociale, and puts up prices

of the Mutuelles.

As Chancer says there is a new category proposed in which the specialist agree to keep the extra within 150%

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              Last year, when it was thought that I would have to have a certain op the anethetist charged over the conventionee. I had to sign a form stating that I would pay. Isn't this normal? It should be, then it wouldn't come as a shock.

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  • 1 month later...

I

need advice regarding Medicare supplement insurance plan one of my friend suggest about it,   As we are 5 members in the family including me, my wife and  2 children aged

5yrs and 11 yrs my father is also staying along with us i need to my

family to be medically secured please suggest some ideas whether can i take

group plan or i hav to take individual plan for each member.

Please suggest !!!

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I think it's individual cover as the cost varies strictly according to age. You need to speak to the providers themselves to see if they will offer group cover.

As an aside, the corrupt format of your post suggests that you may be using Interent Explorer 4, please say that is not so !

Normal

0

false

false

false

MicrosoftInternetExplorer4

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