Care pathway: coordination, what reimbursement?

The coordinated care pathway, established by the law of August 13, 2004 entrust to doctor the role of care coordinator for your medical follow-up. The implementation and respect of the care pathway makes it possible to benefit from the best reimbursement. What is the reimbursement rate when the care pathway is respected? And out of treatment? Who are the specialists outside of the care pathway?

Definition: what is the care pathway?

THE coordinated care pathwayinstituted by the law of August 13, 2004, aims to provide each user with coordinated medical follow-up, rigorous management of medical records and personalized prevention. This presupposes designating a general practitioner who should be consulted preferentially, in particular before any consultation with another healthcare professional (known as the “correspondent”), for additional care or examinations. “Respect for the course of care concerns all the insured persons (beneficiaries of CMU included), and constitutes a condition for being covered with the best reimbursement rate by Health Insurance and complementary health insurance under responsible contracts“, explains Dr. Frédérick Cosnard, Medical Director of Research & Development at Santéclair.

What is the reimbursement rate when the care pathway is respected?

People respecting the care pathway benefit from the maximum reimbursement by their compulsory health insurance fund, or 70% of the consultation fee (-1 € lump sum participation and excluding any excess fees that may be charged)… the remaining 30% is then reimbursed by complementary health insurance. In order to ensure that you are properly enrolled in the course of care to benefit from this maximum rate of reimbursement, you must have said an attending physician and consult:

► As a priority, this attending physiciant, i.e. the one who signed your “Attending Physician’s Choice Statement”.

► Or, if he is absent, another substitute physician.

► Or, if you are away from your place of residence (especially on vacation, or at your place of work, especially if you are traveling, etc.), another doctor of your choice who will have to specify this circumstance on your care sheet.

► And any doctor in case of emergency.

Each insured person has a vital card which allows an electronic care sheet to be generated. “If the Vitale card cannot be used, the healthcare professional will give a manually completed paper care sheet that the patient must send to his health insurance fund“, concludes our expert.

What reimbursements outside the course of care?

In the event of non-compliance with this procedure consisting of first consulting your doctor, the amount of reimbursements is reduced so that it is no longer calculated as:

► On 30% of the amount of the act if it is less than or equal to 25 euros (example: a consultation with a general practitioner in sector 1);

► On a basis of 10 euros for any procedure over 25 euros (example: a consultation with a sector 1 specialist doctor).

“Reimbursements from complementary health insurance are generally indexed to those of the compulsory health insurance fund and therefore also diminished, or even completely non-existent, if the course of care is not respectedsays Dr. Cosnard. You need to check with your complementary health insurance to find out about the specific conditions for reimbursement outside the course of care“.

Who are the specialists outside the care pathway?

Some medical specialties and some health professionals are exceptions to the coordinated care pathway, the patient can then consult them directly without going through his attending physician and without seeing his reimbursements reduced. These exceptions concern the following medical specialties, known as “free access”:

• gynecologistsfor the periodic clinical examination including screening, prescription and monitoring of contraception, pregnancy monitoring or medical termination of pregnancy
• ophthalmologistsfor the prescription and renewal of glasses or contact lenses, screening and monitoring of glaucoma
• psychiatrists or neuropsychiatrists if you are between 16 and 25 years old
• stomatologists for oral procedures (oral preventive care, conservative care, surgical care, dental prosthesis care, dento-maxillofacial orthopedic treatments)
• dental surgeons
• midwives
• medical auxiliaries
• medical analysis and imaging laboratories
• biologists, pharmacists, medical transporters and equipment suppliers (opticians, etc.)

A medical prescription, established by your attending physician or by another physician, is on the other hand almost always necessary to be reimbursed when you use the services of medical analysis and imaging laboratories and biologists, pharmacists, medical transporters and equipment suppliers. . In addition, certain acts and treatments fall within the scope of the exception to the care pathway, even if the patient has not declared a treating physician:

• Organized screening acts as part of the national campaign against breast cancer
• Voluntary termination of pregnancy (IVG) medicated
• Care during hospitalization private or public sector
• Treatments carried out within the framework of a emergency
• Palliative care
• Expertise
• Care abroad
• Anatomo-pathologist acts (biopsy or puncture)

“Consulting a midwife falls within the exception to the coordinated care pathway: the opinion of the attending physician is therefore not necessary and the consultation is covered by health insurance“, specifies our interlocutor. The midwives can intervene within the framework of a follow-up of pregnancy. Thus, they carry out prenatal examinations (ultrasounds, blood tests, etc.) and a post-natal follow-up: consultation of breastfeeding maternal, etc. To be well reimbursed when you consult:

► If you consult an open access specialist directly, without going through your doctor, make sure he ticks the box “Specific direct access” on your care sheet. You will then be reimbursed as normal (provided, however, that you have declared a treating doctor).

► If you consult a medical specialist entering the course of care (such as ENT, gastroenterologist, dermatologist, rheumatologist, cardiologist, allergist, radiologist, etc.), it’s a letter of recommendation from your doctor which guarantees that you are well enrolled in the course of care.

Thank you to Dr. Frédérick Cosnard, medical research & development director of Santéclair, my health benchmark.