The social insurance section of the National Council of the Order of Dental Surgeons must justify its decision by specifying the anomalies found against the practitioner

Published on :
04/15/2022
15
april
apr.
04
2022

Brief reminder of the role of the social insurance section of the disciplinary chambers of first instance of the regional orders of dental surgeons:

Pursuant to the provisions of Article L. 145-1 of the Social Security Code, the social insurance section of the Disciplinary Chamber of First Instance notes and assesses the shortcomings of practitioners that may constitute fault, abuse, fraud and all facts relating to the care provided to the insured persons.

The social insurance section of the National Council of the Order of Dental Surgeons has jurisdiction on appeal.

Article L. 145-2 of the Social Security Code sets the penalties incurred by practitioners.

Thus, the penalties likely to be pronounced by the courts of first instance and by the court of appeal are warning, reprimand, temporary or permanent ban, with or without suspension, of the right to provide care to insured persons. and, where applicable, the reimbursement to the insured of the overpayment or the repayment to the social security organizations of the overpayment, even outside the pronouncement of any sanction.

It should also be noted that identical social insurance sections are set up with the ordinal courts of doctors and midwives.

The Council of State is competent to assess the regularity and the merits of the decisions of the social insurance section of the National Council of the Order.

And the Council of State requires specific reasons for these decisions:

Indeed, in its judgment no. 450279 of April 6, 2022, the Council of State was led to assess the motivation of a decision of the social insurance section of the National Council of the Order, seized on respective appeals from the director of the primary health insurance fund and the medical adviser.

The social insurance section of the National Council of the Order of Dental Surgeons had, by a decision of February 4, 2021 on the one hand, imposed on the practitioner the sanction of the prohibition to provide care to socially insured persons for a period of six months and on the other hand, ordered him to pay the sum of 10,093 euros to the primary health insurance fund.

The practitioner, appealing to the Court of Cassation, sought the annulment of this decision.

First of all, the Council of State began by qualifying the abuse of fees or acts or services carried out under conditions disregarding the rules provided for in Article L. 162-1-7 of the Security Code and this, within the meaning of the provisions of 4°) of article L. 145-2 of the same code.

The Council of State recalls that:

“Constitute abusive fees within the meaning of these provisions those which are claimed for an act invoiced without ever having been carried out, for an overpriced act, for an act carried out under conditions such that even though it was actually performed , it is equivalent to an absence of care, or even those whose amount is established without tact or measure”.

This definition had, for example, already been defined by the Council of State, in its judgment no. 373406 of March 18, 2015, and it is used in identical terms by the social insurance sections of the various orders.

Then in the judgment of April 6, the Council of State adds that:

“(…) the social insurance section of the National Council of the Order of Dental Surgeons, after noting that Mr C… had listed acts which were not reimbursable as well as acts which had not been carried out or noted or backdated acts, that he had practiced the double quotation of the same act in three files and that he had invoiced acts not in conformity with the data acquired by science, judged that he should be condemned to pay the sum of 10,093 euros to the primary health insurance fund of the Loire confining itself to justifying this sum by “numerous anomalies [qui] meet one or more of the conditions mentioned in Article L. 145-2 CSS and constitute abuse of fees “. In so ruling, without specifying, among the anomalies it had noted, those which constituted abusive fees as defined in point 2 or the methods for calculating the amount of the financial penaltythe social insurance section of the National Council of the Order of Dental Surgeons tainted its decision with insufficient reasoning”.

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 engages only its author.

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