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Imprimer cette page
Avant de réaliser son travail, le praticien doit obtenir l'accord de son patient tant en ce qui concerne le type du traitement envisagé que le coût engendré. Cette obligation se caractérise par l'établissement d'un devis écrit qui est obligatoire pour les soins onéreux, les traitements soumis à entente directe et hors nomenclature ainsi que les soins à visée esthétique. Il n'y a pas de devis pour les soins pris en charge par la sécurité sociale et lorsqu'il n'y a pas de dépassement d'honoraire
Cette obligation résulte de l'article 33 du Code de Déontologie des Chirurgiens-dentistes qui stipule que « lorsque le chirurgien-dentiste est conduit à proposer un traitement d'un coût élevé, il établit au préalable un devis écrit qu'il remet à son patient ». L'obligation du devis se déduit également de l'article L1111-3 du CSP : « les professionnels de santé d'exercice libéral doivent, avant l'exécution d'un acte, informer le patient de son coût et des conditions de remboursement par les régimes obligatoires d'assurance maladie ».
Le coût des travaux apparaît donc comme un élément déterminant de l'information qui doit être dispensée par le praticien. Dès lors, le devis s'impose pour les traitements prothétiques, implantaires, orthodontiques, ainsi que pour tout acte hors nomenclature, et doit comporter les éléments suivants : La date d'établissement, l'identification du praticien traitant et du patient, la durée de validité du devis, la description du traitement ou des actes proposés (nature, localisation, matériaux utilisés), la cotation des actes selon la nomenclature, le montant total des honoraires, la base de remboursement pour l'assurance maladie obligatoire ainsi que la signature du praticien et du patient.
La sécurité sociale
Il faudra différencier les actes ayant une cotation sécurité sociale ( SPR pour la prothèse, TO pour l'orthodontie) et les actes Hors Nomenclatures qui sont sans cotation. Pour ces actes Hors Nomenclatures ( implants dentaires, par exemple) il n'y a pas de remboursement de la part de la sécurité sociale.
Les remboursements d'un acte, toujours limités aux frais réels, sont exprimés en pourcentage de la Base de Remboursement (BR) de la sécurité sociale.
La part des dépenses non remboursées, provenant de la différence entre le remboursement de la sécurité sociale et son tarif de base est appelé Ticket Modérateur (TM). Actuellement la sécurité sociale rembourse 70% de cette BR . Le ticket modérateur est donc la différence, soit 30%
La part des dépenses non remboursées provenant de la différence entre les frais réellement payés et le tarif conventionnel est appelé dépassement d'honoraire. Les dépassements d'honoraires nécessitent un devis préalable et l'accord du patient.
Les mutuelles ont pour but de rembourser tout ou partie de ce qui ne l'est pas par le régime obligatoire.
Le remboursement de la sécurité sociale
Exemple pour une couronne
- Codification 1 couronne : SPR50
- Valeur du SPR : 2,15 €
- Base de remboursement ou tarif conventionnel (TC) : 50 x 2,15 € = 107,50 €
- Remboursement SS : 70% du TC = 75,25 €
- Ticket modérateur :TC-Remboursement : 107,50 - 75,25 = 32,25
Le remboursement des mutuelles
Les pourcentages de remboursement des mutuelles s'expriment de 2 manières
1. Soit les pourcentages exprimés comprennent les remboursements SS
Exemple 1 : 100% du TC : la mutuelle vous rembourse 100% de 107,50 € moins le remboursement SS (107,50 - 75,25 = 32,25 de remboursement mutuelle. Total : SS + mutuelle = 107,50)
Exemple 2 : 400% du TC: la mutuelle vous rembourse 4 x 107,50 € moins 75,25 € = 354,75€. Total du remboursement SS + mutuelle = 430 €.
2. Soit les pourcentages exprimés sont en plus du remboursement sécurité sociale.
Exemple 1 : 100% du TC : la mutuelle vous rembourse 100% de 107,50 € soit 107,50 €. Total du remboursement SS + mutuelle = 75,25 € + 107,50 € = 182,75 €
Exemple 2 : 400% du TC: la mutuelle vous rembourse 400% de 107,50 € = 430 €. Total du remboursement SS + mutuelle = 75,25 € + 430 € = 505,25 €
ATTENTION |
Certaines mutuelles expriment leur remboursement non plus en fonction du tarif de convention mais en fonction du remboursement SS voire du Ticket modérateur. Dans ces 2 derniers cas les remboursements sont fortement inférieurs à ceux exprimés en fonction du tarif de convention.
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En conclusion, dans le choix d'une mutuelle vous devez être attentif à 5 mentions :
1. Le pourcentage exprimé2. Le pourcentage exprimé mais en fonction de quoi ?
- le BR ou barème de remboursement ?
- le TC ou Tarif de Convention ?
- le remboursement SS ?
- le Ticket Modérateur ?
3. Le pourcentage de remboursement exprimé inclue-t-il ou non le remboursement de la sécurité sociale ?4. Les remboursements des prothèses dentaires et implants dentaires sont-ils plafonnés ou pas?5. La mutuelle prend-elle en charge les actes HN (Hors Nomenclatures) tel que les implants dentaires ou les actes de parodontologie ?
ATTENTION |
Certaines mutuelles proposent des pourcentages de remboursement avec un plafond annuel. Ce plafond fausse vos remboursements. Le pourcentage exprimé n'a donc de valeur que par rapport au plafond annuel.
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