Patients are often lost and rarely understand what the sums they pay to the doctors they consult correspond to. This is even truer when there are fee overruns. What are the rates according to the doctors consulted?
When you go to the doctor, the price of the consultation may vary depending on whether the practitioner is contracted or not contracted, and its sector of activity (sector 1 or 2). In sector 1, the contracted doctor has prices fixed by a national agreement and does not ask for additional costs: this is the payment for the services rendered by the liberal professionals (such as doctors, notaries, lawyers, architects, etc.). In sector 2, the doctor can request additional costs called excess fees. We take stock.
Definition: what is the difference between a doctor in sector 1 and 2?
When they settle, doctors have the choice of practicing under two different sectors of practice: sector 1 and sector 2. The choice of these sectors define the rates they can apply and the terms of reimbursement for patients.
► The term “registered doctor in sector 1” means that the doctor consulted must apply the rates fixed in the medical agreement, that is to say without exceeding fees. It is these rates that correspond to the reimbursement basis of the Health Insurance. In sector 1, the basis for reimbursement by the Health Insurance is 70% when the patient is in the course of care (ie he has declared an attending physician). Some people are covered at 100%: pregnant women from the sixth month of pregnancy, people covered under a long-term condition (ALD) and people affiliated with the CMU (universal health coverage) or to AME (state medical aid).
►The approved doctor in sector 2 has the possibility of charging free fees. He can exceed fees, but these need to be defined “with tact and moderation”. Then, the Health Insurance reimburses on the basis of the basic rate (70%) but not the amount of the overrun. This is covered by the mutuals (according to ceilings set by each complementary health insurance). In some cases (patients benefiting from CMU-C and ACS), the sector 2 doctor cannot practice overdrafts.
► Finally, a third sector exists: the non-convention sector. Some doctors in France (about 500) have not signed an agreement with Social Security. Their fees are completely free and there is no control over any excess of the rates charged. In this case, Health Insurance only covers a small part of the amount of the consultation: 4 euros for a consultation at 25 euros.
What are the prices of general practitioners?
Since May 1, 2017, the tariff charged by a sector 1 general practitioner has gone at 25 euros (against 23 euros previously). “These increases are no financial impact for policyholders who have supplementary insurance. Indeed, the distribution between the part reimbursed by health insurance and complementary health insurance remains unchanged (70%/30%)“, adds Sandrine Frangeul, deputy of the health professions department at the National Health Insurance Fund. And to emphasize: “The vast majority of general practitioners practice in sector 1 : 54,265 out of a total of 59,417.”. The basis for reimbursement by the health insurance fund, when the patient is in the course of care, is 70%except for people covered at 100% in the context of a long-term illness (ALD list), pregnant women from the 6th month and people affiliated with the CMU or the AME.
What are the rates for medical specialists?
The consultation of a medical specialist in sector 1 is also fixed at 28 euros, except when consulting a psychiatrist, neuropsychiatrist, or neurologist. Then, the price of the consultation in sector 1 is fixed at €43.70. The rate at the cardiologist also differs: in sector 1, the consultation rate is set at €47.73 euros.
| Doctor (sector 1) | Consultation price |
|---|---|
| Generalist | 25 euros |
| Psychiatrist, neuropsychiatrist, neurologist | 43.70 euro |
| Cardiologist | 47.73 euros |
► But it should be noted that these prices may differ depending on the reason for the consultation, the type of examinations carried out. For example, a melanoma screening consultation carried out in the office by the doctor specializing in dermatology is invoiced (in sector 1) 46 euros. The fact of having been directed to a specialist by his attending physician can also modify the price of the consultation. The health insurance holds an up-to-date table on the price of consultations with the specialist on his website.
► Please note: “For specialists, 29,291 doctors practice in sector 1 against 25,089 in sector 2 or in sector 1 with rights to excesses.“
What are fee overruns? In which cases?
Doctors based in sector 2 are empowered to practice excess fees. Their fees are free: they can practice the prices they want, with a fundamental principle: “tact and moderation”. The amount of the excess is not reimbursed by the Health Insurance but their support is possible by the complementary organizations. “In addition, in certain specific situations, overspending is prohibited, for example: practitioners, regardless of their sector of practice, may not overspend on acts and care provided to beneficiaries of CMU-C and ACS (aid for complementary health insurance) as well as on certain clinical acts, which must imperatively be invoiced at an enforceable rate (without overrun) in order to be covered“, specifies Sandrine Frangeul.
What are the prices for home visits?
The price of a visit to a general practitioner at home is fixed at 25 euroswith a travel surcharge of 10 euros. Depending on the time of the visit, other increases are to be expected. From 8 p.m. to midnight and from 6 a.m. to 8 a.m., the generalist consultation at home is increased by 38.50 euros, and by 43.50 euros from midnight to 6 a.m. On Sundays and public holidays, this consultation is increased by 22.60 euros. A home visit qualified as “long and complex”, is it invoiced on a basis of 60 euros.
| Visiting time | Consultation price |
|---|---|
| 00:00 a.m. to 6:00 a.m. | 25 euro + 43.50 euro |
| 6:00 a.m. to 8:00 a.m. | 25 euro + 38.50 euro |
| From 8:00 a.m. to 8:00 p.m. | 25 euros |
| From 8:00 p.m. to 12:00 a.m. | 25 euro + 38.50 euro |
| Sundays and public holidays | 25 euro + 22.60 euro |
The rates for home visits by specialist doctors are the same, except for psychiatrists, neuropsychiatrists, neurologists, who charge for this visit 39 euros.
Prices for children’s consultations
The cost of consultations for a child is slightly higher than for an adult. Up to 6 years, the consultation with the general practitioner is set at 30 euros. The price of consultations with a pediatrician is set at 32 euros. “By setting slightly higher rates for consultations with young children, we take into account in particular the fact that they are patients that require more time and special attention“, explains Sandrine Frangeul.
Display of prices: a legal obligation
To find out if a practitioner practices in sector 1 or 2, the Health Insurance has put a directory of health professionals online on its site. This directory indicates the sector but also the rates applied. All doctors, regardless of the sector they have chosen, are also required to display their rates in their practice.
Thanks to Sandrine Frangeul, assistant of the health professions department at the National Health Insurance Fund.