Healthcare in France may not be free at the point of delivery, but many patients are able to obtain treatment without the need to make a payment.

Whilst in the UK health treatment is free at the point of use, and doctors paid on a per patient basis, in France it operates somewhat differently.

Under the French health system the accounting system is activity based. That is to say, doctors charge a fee to each patient for a consultation, who is then required to make a claim for reimbursement from the social security authority and their complementary health insurer. Depending on the circumstances the reimbursement may be full or partial.

In practice, the differences between the two systems are not so wide, for in most cases the consultation fee is paid directly by the social security system, as well as the complementary health insurer, provided the patient holds such a policy. In addition, the majority of hospital doctors in France are salaried or work on a hybrid basis, and around one-third of GPs are salaried.

This system of direct payment is called tiers payant - a phrase that has no meaningful translation in English, but literally means 'third-party payment'.

Many patients automatically benefit from tiers payant for that part of the charge reimbursable by the state, notably:

• Those who have been admitted to hospital;
• Those suffering from a major or long-term illness - affection longue durée (ALD);
• Beneficiaries of the Couverture Maladie Universelle Complémentaire (CMC-C);
• Beneficiaries of Aide à l’acquisition d’une Complémentaire Santé (ACS) ;
• Those suffering from a work-related illness or disease;
• Pregnant mothers;
• Those undertaking organised screening, such as a mammography.

In other cases doctors have the discretion to decide whether they are prepared to accept it, but it is in operation in the majority of GP surgeries.

If the patient has a complementary health insurance policy many GPs also offer the tiers payant mutuelles/complémentaire, under which the insurers are notified of their charge by the social security system and the doctor is reimbursed by them. The practice is less common among specialist consultants and dentists.

Where complete direct payment occurs then the tiers payant process is called ‘intégral’; where only the state reimbursable part of the charge is paid direct then it is stated to be ‘partiel’, unless that charge is fully reimbursable by the state.

The process is also in place for laboratory tests and x-rays and has been used by pharmacies for many years, where it is almost universal. Thus, if you visit a chemist armed with a prescription from your doctor that part of the charge reimbursable by the health system will be paid directly, with any balance payable direct by your insurer, subject to the terms of your policy. Only if you refused a generic medicine, in lieu of a branded medicine, would a chemist not offer it, unless your doctor had made it clear the prescribed medicine could not be substituted.

The system of tiers payant does not always mean that all charges will be covered. Some charges may remain the responsibility of the patient, such as the various 'participations forfaitaires', which will appear on your medical treatment and bank statements. If you do not have complementary health cover that part of the charge not reimbursed by the state will be payable by you at the point of delivery.

In addition, an increasing number of consultants impose charges over and above the official tariff. These charges are called dépassements d'honoraires. The extent to which they are picked up by your complementary policy will depend on the terms of the policy.

Last year, the system of tiers payant for the charge reimbursable by the state was scheduled to be rolled out to all patients and all treatments. However, there has been resistance to the change from the medical profession, who consider that there remain many technical barriers to the adoption of the system, such that payment for the consultation cannot be guaranteed. As a result, the government have backed off and the existing arrangements remain in place whilst a working party examines the issue in greater detail.

No Health Card

The system of tiers payant is only possible once you have obtained your health card, your ‘carte vitale’, which contains a microchip that is used to process payments. 

When you visit your doctor or chemist, the card is merely inserted into a card reader and no cash changes hands. Not all doctors accept the card (they do not want the administrative work that is involved), but it is used by around 90% of GPs and two-thirds of consultants.

Prior to obtaining your carte vitale you will need to pay for treatment at the point of care, for which you will be given a receipt, called a feuille de soins, which you send to your local health authority for reimbursement (full or partial) to be made.

If you also have complementary health insurance, most insurers are linked into the social system through which their share of the charge will also be reimbursed.

If no direct payment by your 'mutuelle' is in place you will need to send the receipt for payment - relevé de remboursement - you receive from the health system to your insurer.