Consultation with a specialist and general practitioner

HEYME supplementary health insurance

You need to consult a specialist but you never know whether or not you should go through your doctor beforehand? Have you ever heard of the healing journey but only have a vague idea of ​​what it means?

Are you a little lost with these notions? No worries ! We’re here to help you see it more clearly 😉

What is the coordinated care pathway?

The coordinated care pathway is a system that consists of consulting your own doctor before consulting another general practitioner or specialist, called a corresponding doctor. It concerns all insured persons affiliated to Social Security, aged 16 or over.

Thanks to the coordinated care pathway, you benefit from coordinated medical follow-up, rigorous management of your medical file and personalized prevention.

Respecting the coordinated care pathway absolutely requires declaring your attending physician to Social Security and therefore consists of going through the latter before consulting a specialist.

Compliance with this approach determines the coverage of your health expenses. This allows you to be better reimbursed by health insurance and supplementary health insurance responsible.

If you do not respect the course of care, you will be considered out of course of care, which will greatly reduce your reimbursements. Indeed, in the case of a consultation outside the course of care, the Health Insurance increases the co-payment, that is to say your remaining charge. It reimburses you up to 30% of the social security reimbursement base, and no longer 70%. And if you are covered by complementary health insurance under a responsible contract, your mutual insurance company will not be able to complete this reimbursement.

In short, the impacts are far from neutral for your budget.

Whether or not you have declared an attending physician, there are however exceptions to the coordinated care pathway.

HEYME supplementary health insurance

Exceptions in the coordinated care pathway

Exceptions to the care pathway allow you to consult doctors with specific direct access, i.e. without going through your general practitioner first. These consultations will not be subject to an increase in your co-payment. You will not be considered outside the coordinated care pathway. You will therefore be reimbursed by Health Insurance up to 70% of the Social Security reimbursement base. And your mutual will be able to complete the reimbursement.

The first exception to the coordinated care pathway has been provided for those who have declared an attending physician, in cases where the latter cannot be consulted:

  • Your attending physician is absent or unavailable;
  • In case of displacement or distance from your usual residence and therefore from the place of practice of your attending physician;
  • The doctor consulted has been established for less than 5 years;
  • In the event of an emergency, i.e. a “situation not foreseen more than 8 hours previously and which concerns an illness, or the suspicion of an illness, involving your life or the integrity of your body and leading to the rapid mobilization of the doctor”.

The second exception to the care pathway has been planned to facilitate your access to care, with certain specialists having de facto specific direct access.

The specialist physicians with direct access are as follows:

  • ophthalmologists : for a prescription or renewal of corrective glasses or contact lenses, screening procedures or monitoring of glaucoma;
  • gynecologists : for regular gynecological clinical examinations, screening procedures, or pregnancy monitoring (ultrasounds, etc.);
  • psychiatrists or neuropsychiatrists, if you are between 16 and 25 years old;
  • stomatologists ;
  • dental surgeons;
  • Biologists.

Finally, certain care can also be carried out within the framework of the exception to the coordinated care pathway. You are also not considered out of the care pathway in the following cases:

  • In the event of a care protocol established for an exonerating long-term condition (ALD);
  • In case of follow-up with a specialist doctor in the context of a chronic illness;
  • If it is a follow-up consultation with a specialist doctor;
  • During a care sequence in consultation with the attending physician;
  • In the event of hospital consultations for smoking, alcoholism or the fight against drug addiction.

Specialists to be consulted through your attending physician

On the other hand, to consult certain other specialists, you will necessarily need a letter of recommendation from your attending physician.

These are the following:

  • ENT;
  • The gastroenterologist;
  • The rheumatologist;
  • The cardiologist;
  • The allergist;
  • The pulmonologist;
  • The urologist;
  • The radiologist;
  • The neurologist;
  • The dermatologist;
  • The nutritionist.

Coordinated care pathway and follow-up consultations with a specialist

Once you have been referred to a specialist by your GP, you can consult this specialist again without having to go through your GP. The only condition is that it is a follow-up consultation.

Indeed, the medical specialist may need to see you regularly to monitor your pathology. No need then to go through the attending physician before each follow-up consultation. You are in the device of the care pathway.

Keep in mind that this only applies to follow-up visits. If you wish to consult this medical specialist again following a new illness, you must first go through your general practitioner. He alone will be able to estimate whether or not it is necessary to consult a specialist for this pathology or these symptoms. He may, for example, prescribe additional examinations before whether or not to refer you to his colleague.

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