Reimbursement of care: what is it?
The patient should set itself the amount of its care from health professionals that he uses. This is the principle of the advance fee. It is up to him to be then reimbursed by the Social Security Agency and its mutual.
However, in case of hospitalization, occupational disease or accident, the patient can be taught to do this upfront fee. This is what we call the third-party payer. In this case, the patient pays only the co-payment, that is to say, the amount remaining in office, the refundable portion of care is paid directly to the provider and the health insurance agency.
What are the economic and human issues?
One of the few developed to promote direct payment for health care professionals and health reimbursement on insured countries. Numerous studies have shown that not having to do the upfront fee facilitates access to care, particularly for the most disadvantaged.
However, with the widespread use of third-party payment and use of increasingly common Vitale card, the actual cost of care is becoming increasingly difficult to design for people who benefit from it, even though each insured person's finances collectively their Social Security taxes.
In 2007, total health expenditure French amounted to $226.5 billion, which represents nearly 11% of the national wealth and that puts our country in third expenditure in terms of health among developed after the United States (15.3%) and Switzerland (11.3%). country
These expenses increased by 4.7% compared to 2006.
What does it take to be reimbursed?
In general, to be repaid, care or health products including drugs must be on the list of acts or products reimbursed by social security, be prescribed by a doctor (or a dentist or a midwife), and dispensed by a health care professional to do so.
To be reimbursed, it is sufficient if the rights to health insurance to the insured are open to apply by filling out the sheet of care delivered by the health professional, attesting fees received and the payment the amount of benefits. On the address with the order and supporting documents may be required, at the center of Social Security.
With the Carte Vitale, all of these procedures are done automatically. Just present it to health professionals.
In which case a prior agreement is needed?
Some treatments require to be repaid, an agreement of insurance before being made disease. This is what is called the prior agreement.
It is indispensable for acts of Dentofacial Orthopedics, for certain laboratory or medical equipment for ambulance transport serial or over long distances, and from 30 sessions massokinésithérapie.
The request for prior agreement is filled with the health professional and addressed by the insured to the health maintenance organization, which has a period of fifteen days to respond. Failure to respond within this period amounts to an agreement.
When can we benefit from the third-party payment?
Legal paying client is mainly reserved for patients who have suffered an accident at work or an occupational disease, those who benefit from the complementary Universal Health Coverage (CMUc) and beneficiaries of the State Medical Aid ( AME).
It is also applied to in-patients.
It is increasingly common in pharmacies and medical laboratories. But in this case it depends on agreements between health professionals and health insurance providers. Its management is also often offered by mutuals.
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