Operation hallux valgus: social security refund
Operation hallux valgus and reimbursement by social security: Doctor Julien Lopez explains the management of this surgery.
In France, “social security” refers to the primary health insurance fund (CPAM). The beneficiaries are called “rights holders”. In the French Overseas Territories, health reimbursement is administered by the Caisse Générale de Sécurité Sociale (CGSS). In Monaco, the Social Funds of Monaco (CSM) contain the social services compensation fund (CCSS).
Depending on which fund you belong to, the repayment schemes differ. But what about the hallux valgus surgery or “foot onion”? Doctor Julien Lopez gives you an insight into the reimbursement of surgical procedures and more specifically, about the management of hallux valgus.
Operation hallux valgus: social security support in France
Regarding the operation of the hallux valgus, is the support provided by the French social security system fully comprehensive?
Universal Health Coverage (Puma) has replaced UCC (Universal Health Coverage). It allows anyone who works or is permanently domiciled in France to benefit from a full reimbursement of the health costs they need.
Social security fees (fees) are then reimbursed 100% by CPAM. But what about fee overruns?
Reimbursement of medical procedures
When you arrive at a health care facility or a practitioner, simply giving your health card allows you to benefit from health insurance. The latter materialize in the form of a reimbursement of consultations and medical procedures. Surgical procedures, implants and other medical treatments required by the patient at the time are partially or fully reimbursed by CPAM.
It is important to emphasize the medical nature and the need to perform these acts because aesthetic or “comfort” interventions are not covered by social security.
Depending on the contract area to which the medical practitioner belongs, the reimbursement of his acts will be different.
Practitioners with sector 1 agreements: 100% support
Doctors with sector 1 agreements set the rates imposed by the health insurance. They have no power over the implementation of their tariffs because CPAM determines them.
Their consultations and medical procedures are 100% reimbursed by the organization.
Practitioners covered by sector 2 agreements: coverage excluding excess fees
Dr. Lopez is a contractor in Area 2. Area 2 is also referred to as a fee-free contractor. This means that specialist practitioners with sector 2 agreements can apply fee overruns.
The reimbursement of CPAM will be effective only on the agreed rate. Excesses will not be covered by the organization. On the other hand, excess fees can be reimbursed by your insurance based on the offer of your contract. In order to get a precise idea of the "remainder à charge", the secretary gives you a quote that must be sent to your insurance company.
As for medical practitioners with sector 3 agreements, they set their tariffs freely.
CPAM is the French entity reimbursing medical expenses due to consultations or surgical procedures. Do you live in Monaco? Doctor Julien Lopez gives you details on the repayment schemes of this city-state.
Operation hallux valgus: reimbursed in Monaco
The operation of the hallux valgus is reimbursed differently in the city-state of Monaco. Since the health insurance fund is not identical to the one in France, the conditions and terms are different. Dr Lopez has a contract with the CCSS of Monaco.
Three cards characterize the tariffs set up by Monegasque practitioners, as do the sectors covered by the agreements in France:
The green card: like the sector 1 convention in France, the practitioners holding it put in place the conventional tariffs imposed by the organization. The remaining charge for the patient is 0 euro.
The pink card: allows healthcare professionals to set up fee overruns of 20%. The excess fee is 160 euros (surgery and anesthesia fee), it can be reimbursed by the mutual.
The “bulle” card: practitioners can apply the rates they want, with the patient’s agreement.
In these three cases, the CCSS (social services compensation fund) pays 100% of the agreed rate. The excess (in case of pink card or bulle) will be the subject of a quote. Once sent to your mutual, the expenses will be refunded in full or in part, depending on the scheme subscribed.
Lopez’s bunion surgery is supervised and respects the conventions of the health insurance funds of the patients he receives. ATTENTION: Despite the agreement signed between the Monegasque CCSS and Dr. Lopez, the patient must advance all hospital and surgical expenses when leaving the clinic. These expenses will be reimbursed in full directly to the patient (excluding any fees that may be reimbursed by your insurance) by the CCSS.
Hallux valgus surgery: reimbursement by Doctor Lopez
Hallux valgus surgery and reimbursement, what are the practices of Doctor Julien Lopez?
Under the Sector 2 agreement, it sets up fee overruns “framed” and accepts the “carte vitale”.
The costs of the hallux valgus surgery performed by Dr Lopez are then divided between:
The agreed rate, imposed by the sickness insurance fund
Fee overruns determined by the practitioner, within a specific legal framework
The costs of the operation carried out are then 100% covered by social security, excluding excess fees. In order to be reimbursed, the practitioner will send the estimate to the insurance company who, depending on the scheme subscribed, will refund part of the remaining amount or its entirety. On average, patients have to pay, after all the treatments applied, 300 euros for a hallux valgus operation to eliminate their daily discomfort.
Operation hallux valgus: Private insurance
If you have international insurance, a quote will be given to you by the secretary. This quote must be sent to your insurance company. After studying your file and after agreement in principle, the surgery of hallux valgus can be scheduled.
