Excess medical fees and OPTAM (France)

In France, the national health insurance reimburses consultations on the basis of an agreed tariff. So-called sector 1 doctors apply this tariff; sector 2 doctors may set their own fees and charge an excess, which neither social security nor often the supplementary insurer fully reimburses. Excess fees are concentrated in certain specialties, surgery, gynecology, anesthesia, and certain cities, and account for a large part of patients' out-of-pocket costs. To moderate them, the medical agreement created in 2017 the controlled pricing option, which succeeded the 2013 access-to-care contract. A doctor who joins commits not to exceed an average excess rate and to perform a share of procedures at the base tariff; in exchange, the doctor's patients are better reimbursed. Responsible contracts organize the same sorting on the supplementary side: they may reimburse the excess fees of participating doctors, but must cap those of non-participants, at 100 percent of the base tariff and at a lower level than for participants. For health insurers, excess fees are a hard-to-control expense and a source of top-up contracts, which cover what the responsible contract is not allowed to reimburse.