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Specialist healthcare

Specialist healthcare

Old Aug 7th 2019, 11:01 am
  #1  
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Default Specialist healthcare

Hi All,
We just visited the local hospital with a letter of reference to make an appointment for my wife. We were told that the next available was at the end of the year. That in itself isn't a problem, but a couple of other things have come up that I wasn't aware of.
The secretary said that the consultation was not covered by the carte vitale. I understood that specialists charge more and that hopefully they have signed up to OPTAM. It's certainly possible that with my less than perfect French it was simply that we had to pay everything ourselves and then claim it back as normal i.e. they wouldn't do the paperwork themselves. Is that the case? My wife's condition is life long so we should get it all back eventually.
The second question concerns the reference from a doctor. As I said in another thread we have not been able to register with a doctor since they all seem to be full in Carcassonne. We got a letter of reference by visiting a doctor with whom we are not registered, but I just read an online blog saying that if you don't have a reference from your medecin traitant you can not claim much back except in four medical circumstances, none of which apply to my wife.
Will we be refunded for everything with a life long condition or only the drugs? If everything, it doesn't matter about the reference if we can afford to pay up front for the care.
If it's only the drugs maybe we should wait until we have tried every doctor here before taking the reference to a specialist.
Any ideas.
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Old Aug 7th 2019, 3:54 pm
  #2  
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Default Re: Specialist healthcare

Originally Posted by Alianco View Post
Hi All,
We just visited the local hospital with a letter of reference to make an appointment for my wife. We were told that the next available was at the end of the year. That in itself isn't a problem, but a couple of other things have come up that I wasn't aware of.
The secretary said that the consultation was not covered by the carte vitale. I understood that specialists charge more and that hopefully they have signed up to OPTAM. It's certainly possible that with my less than perfect French it was simply that we had to pay everything ourselves and then claim it back as normal i.e. they wouldn't do the paperwork themselves. Is that the case? My wife's condition is life long so we should get it all back eventually.
The second question concerns the reference from a doctor. As I said in another thread we have not been able to register with a doctor since they all seem to be full in Carcassonne. We got a letter of reference by visiting a doctor with whom we are not registered, but I just read an online blog saying that if you don't have a reference from your medecin traitant you can not claim much back except in four medical circumstances, none of which apply to my wife.
Will we be refunded for everything with a life long condition or only the drugs? If everything, it doesn't matter about the reference if we can afford to pay up front for the care.
If it's only the drugs maybe we should wait until we have tried every doctor here before taking the reference to a specialist.
Any ideas.
Hi, is your wife's life-long condition in the ALD category, as per the link below? In which case you must find a Médecin Traitant and he/she will apply to the CPAM for a change of your wife's status for that disorder, and anything associated with it SHOULD be free.
Otherwise I don't know what to advise....
Specialists often don't have the machine for processing the Carte Vitale and you pay upfront - they give you a form ("Feuille de Soins") to fill in and send to your CPAM for reimbursement. I know that, if there's no referral from your MT, the CPAM reimburses less, but I don't know by how much. Have you got a Mutuelle, which might make up some of the difference? I say MIGHT, as it depends on what coverage you opted for.
I've just noticed that the link mentions "Hérault" since I live here, but the info is national.
HTH
https://www.ameli.fr/herault/medecin...definition-ald
P.S. Keep trying to find an MT, you've got time before the appointment!

Last edited by dmu; Aug 7th 2019 at 3:56 pm.
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Old Aug 7th 2019, 7:36 pm
  #3  
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Default Re: Specialist healthcare

Thanks DMU, I hadn't seen the ALD list. My wife's condition is a bit borderline depending on how they measure 'grave' (I can't imagine a non grave version of the condition). I'm sure you're right about us keeping on looking for a medecin traitant. We do have mutuelle insurance. I guess we'll just have to find out what we will be able to reclaim. As it is we can afford the drugs now so it can only get better to some degree.
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Old Aug 8th 2019, 8:13 am
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Default Re: Specialist healthcare

I agree with DMU.
You only get 100% refunds if your wife's ALD is recorded by CPAM, and it is only recorded once your MT has diagnosed it and notified it to CPAM. I don't know if a doctor who is not your MT can do this, but I suspect not.
You do get less back all round for consultations with and referrals by doctors other than your MT. It's CPAM's way of encouraging everyone to register an MT. The health service had a big publicity drive a few years back (maybe still do) to explain the correct way to use the health service - register an MT, keep your CV updated, etc etc etc. - and they had a checklist printed on all the paperwork they sent out.
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Old Aug 8th 2019, 12:19 pm
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Default Re: Specialist healthcare

Thanks for the replies. In case anyone comes across this thread with a similar problem there is a way round ALDs without a medecin traitant.
Go to the AMELI website
Click on 'Droites et demarches'
Click on 'Reclamation, mediation, voies de recours'
Click on 'Comment saisir le mediateur'
Low down on that page is a form called 'Difficulties d'access a un medecin traitant'. Fill that in and send it to mediation.cpam-aude(in my case)@assurance maladie.fr. They can't help you find an mt, but this should allow you to be properly reimbursed without one.
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