The Social Insurance section of the National Council of the Order of Dental Surgeons should justify its decision by identifying the anomalies found to the practitioner.

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release date:
April 15, 2022
15
April
April
04 04
2022

A brief reminder of the role of the social insurance section of the disciplinary room of the first instance of the dentist’s regional order:

In accordance with the provisions of Article L.145-1 of the Social Security Act, the Social Insurance section of the First Trial Disciplinary Action shall consist of practitioners who may constitute all facts related to negligence, abuse, fraud, and care. Record and evaluate shortcomings. It will be provided to the insured.

The social insurance department of the National Council of Dentists has jurisdiction over the appeal.

Article L.145-2 of the Social Security Act stipulates penalties for practitioners.

Therefore, the penalties that may be sentenced by the Court of First Instance and the Court of Appeals are warnings, reprimands, temporary or permanent prohibitions of the right to provide care to the insured, with or without suspension. .. Repayment to the overpaid insured or to the overpaid Social Security Institution, even outside the declaration of sanctions.

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It should also be noted that the same social insurance section is set up in the usual courts of doctors and midwives.

The State Council has the ability to assess the regularity and benefits of the decisions of the Social Insurance Department of the National Order Council.

And the State Council demands specific reasons for these decisions:

In fact, in Judgment No. 450279 of April 6, 2022, the State Council Motivation for the decision of the Social Insurance Department of the National Order Council, seized by the respective appeals from the Board of Directors of the Primary Health Insurance Fund and medical advisors...

The Social Insurance Department of the National Council of Dental Surgeons, on the other hand, has imposed sanctions on practitioners banning the provision of six years of care to social insureds by a decision of February 4, 2021. Meanwhile, he ordered the primary health insurance fund to pay a total of € 10,093.

The practitioner who filed a complaint with the Court of Cassation called for the decision to be abandoned.

First of all, the State Council begins by recognizing abuse of fees, acts or services performed under conditions that disregard the rules set out in Section L. 162-1-7 of the Social Security Code. I did. 4 °) provisions of article L.145-2 of the same code.

The State Council recalls the following:

“Within the meaning of these provisions, it was performed under conditions that were previously unclaimed, expensive, and even if actually performed, were equivalent. The lack of care that constitutes the abuse fee charged for the act, or even the amount established without tact or measurement. “

This definition, for example, was already defined by the State Council in Judgment No. 373406 of March 18, 2015, and is used in the same term in the social insurance sections of various orders.

Next, in a ruling on April 6, the State Council added:

“(…) After pointing out that the Social Insurance section of the National Council of Dental Surgeons listed Mr. C’s actions that were not performed, were not recorded, or were not reimbursed, as were past actions. , He double-quoted the same act in three files, confirmed that he claimed an act that did not comply with the data obtained by science, and should blame him for paying a total of € 10,093 to Loire’s major health insurance fund. I decided that. “Limit yourself to justifying this total by a number of anomalies [qui] Article L 145-2 Meets one or more of the conditions set forth in the CSS and constitutes a charge abuse.To calculate the amount of monetary penaltyThe social insurance department of the National Council of Dentists has polluted the decision for inadequate reasons.

Ainsi, le Conseil d’Etat considère que pour être suffisamment motivée, la décision de la section des assurances sociales du Conseil national de l’Ordre, doit reprendre précisément les griefs constitutifs d’honoraires abusifs, tout en précisant les modalités de calcul du montant de la sanction pécuniaire.

This article is for its author only.