You have finally made an appointment with a specialist. But when you look at the price, you get a bad surprise: the consultation costs twice as much as the Health Insurance reference price. So, should you systematically look for a sector 1 doctor? Frédéric Bizard, economist specializing in social protection and health issues, answers us.
Sector 1 or sector 2: which doctor to choose to pay less?
The first good reflex before making an appointment? Check the area in which the doctor practices.
- In sector 1the practitioner applies the conventional rates set with Health Insurance. Overtaking is therefore very regulated;
- On the other hand, in sector 2the doctor may charge excess fees which are not reimbursed by Health Insurance.
On paper, the choice therefore seems obvious: to pay less, we should favor sector 1. But in certain territories, these doctors are fewer in number. And getting an appointment may take longer.
Then, of course, we must not confuse price and quality of care.
“Sector 1 or sector 2 does not allow us to judge the quality of the care. It first provides information on the way in which the doctor sets his fees”, recalls Frédéric Bizard.
In other words, choosing a sector 1 doctor can limit your out-of-pocket costs, but that says nothing about the competence of the practitioner.
How do I know the “real” price of a consultation?
There is no need to wait in limbo: the Ameli health directory allows you to check whether a practitioner practices in sector 1 or sector 2. Then, if these prices are not clearly indicated, a phone call to the secretariat can avoid an unpleasant surprise.
“The patient should be able to know what to expect. Overpayment should not be something that is discovered when paying,” underlines Frédéric Bizard.
Indeed, if any sector 2 doctor is authorized to practice excesses, these must be fixed “with tact and measure“, recalls the economist.
In sector 2, see if the doctor adheres to OPTAM
Have you found a specialist in sector 2? In this case, check if it adheres to OPTAM, the Controlled Pricing Practice Option. This system aims to limit fee overruns. It also allows patients to benefit from a more favorable reimbursement basis, aligned with that of sector 1.
Be careful, however: OPTAM does not mean “without excess”:
“It is simply a form of price moderation. It does not eliminate overruns, but it allows them to be contained and to have a more favorable reimbursement basis,” explains Frédéric Bizard.
And here the difference can quickly be felt on the bill. For a consultation at 80 euros, for example, the reimbursement base is 31.50 euros. The rest corresponds to the excess fees. Health Insurance does not reimburse it. It is therefore the mutual which can take part, or even all, depending on the contract.
“The excess of fees must therefore be looked at in parallel with what the mutual insurance contract provides. This is where things become much more complex for the insured,”
warns the economist.
And this is precisely where the choice of complementary health insurance becomes important.
100%, 150%, 200%: be careful that your mutual insurance really reimburses
This is often where the system becomes difficult (if not impossible!) to follow.
A mutual insurance company can announce coverage at 100%, 150% or 200% of the reimbursement base. But these figures do not correspond to the percentage of the bill that will be reimbursed. A 150% guarantee means that the total coverage of Health Insurance and complementary insurance can reach 150% of the reimbursement base, within the limits provided for in the contract.
Let’s take for example a consultation whose reimbursement base is 31.50 euros. At 100%, total coverage can reach 31.50 euros. At 150%, it can go up to 47.25 euros. At 200%, up to 63 euros.
If the doctor charges 80 or 90 euros, a significant portion may therefore remain the responsibility of the patient, even with a mutual insurance company offering a 200% guarantee.
“The problem is that policyholders do not always think based on the reference rate. They see 150% or 200% and think they are very well covered, whereas it depends on the amount of the reimbursement base.” explains Frédéric Bizard.
In other words, the percentage displayed by the mutual is not enough. You need to know the basis on which it is calculated.
Another element not to forget: the fixed contribution of 2 euros (since 2024), which applies in particular to doctor’s consultations for the people concerned. It remains the responsibility of the insured and is not refundable.
How then to choose a good “complementary”?
“You have to start from your needs, that’s the golden rule. Above all, don’t start from the mutual offer!” advises the economist.
Indeed, a person who consults a specialist several times a year (psychiatrist, gynecologist, etc.) with excess fees will not have the same needs as a person who mainly consults doctors without excess fees.
“We have to look at what we actually pay over a year and what the mutual insurance covers,” continues Frédéric Bizard.
In other words: “there is no point paying for additional guarantees if they do not meet your needs. You have to look at what is actually used”,
insists the specialist.
The really good idea: staying on the coordinated care pathway
Another possible lever: remaining in the coordinated care pathway. In this scenario, reimbursement is generally more favorable than when consulting outside the course. What if the excess seems too great? Nothing stops you from talking about it with your doctor.
“No doctor has the right to refuse patients who cannot afford to pay. He This is a fundamental principle and your rights deserve to be known and respected.”
concludes the specialist.
To limit fee overruns, the simplest thing is… to anticipate. Before making an appointment, check the doctor’s area on the Ameli health directory. If he works in sector 2, see if he is a member of OPTAM. Then check the advertised price and compare it with the guarantees of your supplement. And if you can’t find the said price, call the secretariat.