Contrôles T2A : le dossier médical, une condition de la facturation ?!

FlickR - No controle (in control) - renatotargaLorsqu’il a été écrit par votre serviteur que la Cour de cassation rendait une jurisprudence souvent, si ce n’est systématiquement, favorable aux caisses (et donc défavorables aux établissements), ce n’était pas une métaphore.

Nous en avons la preuve supplémentaire. Aux yeux de la Cour de cassation, le dossier médical constitue l’alpha et l’oméga de la preuve d’une hospitalisation, générant une facturation subséquente. A défaut de communiquer le dossier médical aux médecins-conseils des organismes d’assurance maladie, ces derniers considèrent que le patient… n’est pas venu.

En l’espèce, la CPAM des Pyrénées-Orientales a notifié à la clinique Saint-Pierre de Perpignan le rejet de plusieurs de ses factures relatives aux soins de 34 assurés (prestations effectuées en 2007, 2008 ou 2009), au motif de l’incompatibilité du numéro de GHS facturé avec l’acte CCAM.

Par courrier du 9 avril 2008, la clinique a saisi le Tribunal des affaires de sécurité sociale (TASS) de Perpignan pour le paiement des factures aux motifs que l’acte a été réalisé conformément aux dispositions de l’article 6-10° de l’arrêté du 27 février 2007 et qu’il remplissait toutes les conditions posées par ledit texte. Elle a ajouté que :

« certains actes d’abord rejetés ont été reconnus postérieurement comme ne pouvant pas être pratiqués en externe dans le cadre de l’arrêté du 25 janvier 2008. La CPAM a sollicité l’avis du médecin-conseil (…), lequel a répondu qu’aucun avis technique n’était possible en l’absence de communication des dossiers médicaux. Il convient de constater que la CPAM des Pyrénées-Orientales a rejeté la facture sans pouvoir en expliquer les raisons, motif pris que le médecin conseil, dont l’avis s’impose à l’organisme, n’a pu examiner et se prononcer sur les dossiers médicaux qui doivent retracer le processus d’hospitalisation conformément à l’arrêté du 27.02.2007. La clinique a circonstancié l’établissement d’un GHS en exposant que :

– « le patient a bénéficié d’une prise en charge administrative d’une chambre, d’un brancardage, d’une prise en charge chirurgicale, d’un plateau technique (ampli de brillance), d’une surveillance postopératoire et d’une sortie.

– ce n’est pas parce qu’une anesthésie est locale que le risque de choc ou d’allergie est inexistant ; l’ablation de broche nécessite un milieu aseptisé.

– ce n’est parce qu’une prise en charge est courte qu’elle n’est pas sans risque ».

En l’état, la clinique a justifié suffisamment sa position, que la CPAM des Pyrénées-Orientales n’a pu contre-indiquer, et elle est en droit de réclamer le paiement de la facture. »

Le jugement du TASS de Perpignan en date du 12 février 2010 a donc donné gain de cause à la clinique demanderesse.

Le montant des sommes en jeu étant inférieur à 4.000 euros, la caisse d’assurance maladie s’est pourvue en cassation.

Dans son arrêt du 17 mars 2011 ((Cass. Civ. 2ème, 17 mars 2011, CPAM des Pyrénées Orientales c/ Société Clinique Saint-Pierre, n°10-16.107 et suivants.)), la Cour de cassation ne l’a pas entendu de cette oreille, et au visa des articles L.162-22-6 et L.162-26 du code de la sécurité sociale, ensemble l’article 6, I, 10° de l’arrêté ministériel du 27 février 2007, relatif à la classification et à la prise en charge des prestations d’hospitalisation pour les activités de médecine, chirurgie, obstétrique et odontologie et pris en application de l’article L.162-22-6 du code de la sécurité sociale, elle a considéré :

« Qu’en statuant ainsi, alors qu’en l’absence de communication par la clinique du dossier médical qui doit être constitué conformément à l’article R.1112-2 du code de la santé publique et auquel, selon l’article L.1112-1 du même code, ont accès les médecins-conseils des organismes d’assurance maladie, la caisse était empêchée de vérifier la nécessité de l’hospitalisation dont le paiement était réclamé, le tribunal a violé les textes susvisé ; « 

Que penser de cette décision ?

Il s’agit tout d’abord, à n’en pas douter, d’un arrêt de principe, dont toutes les juridictions inférieures (TASS et Chambres sociales des cours d’appel) devront nécessairement tenir compte, lorsque des contentieux de cette nature seront présentés devant eux, ou en cours d’instance.

Il est vrai que le dossier médical doit être constitué, conformément aux dispositions de l’article R.1112-2 du code de la santé publique. Il n’est pas davantage inexact que les médecins-conseils ont accès au dossier médical, suivant les termes de l’article L.1112-1 du code de la santé publique.

Par combinaison de ces deux articles, la Cour de cassation affirme que le dossier médical est une condition de la facturation d’un GHS. Cette position est critiquable à plus d’un titre. Qu’un établissement de santé soit incapable de produire un dossier médical, voilà qui témoigne d’un système d’information et d’archivage gravement défaillant, situation tristement banale, qui plus est. Pour autant, et sans connaître le détail du dossier, il apparaît manifestement que l’établissement de santé privé avait parfaitement objectivé la réalité du séjour des patients considérés.

S’agissant du lien dossier médical/facturation d’un GHS, nous invitons les lecteurs à se reporter aux pages 18-19 du document téléchargeable ici.

Au-delà du texte même de la décision, l’arrêt de la Cour de cassation intervient dans un contexte particulier de modification de la procédure de contrôle externe de la tarification à l’activité. En effet, un projet de décret récemment soumis aux fédérations hospitalières vise principalement à améliorer la procédure du point de vue du contradictoire, modifiant les articles R.162-42-9 à R.162-42-13 du code de la sécurité sociale. Un projet d’instruction voit également le jour.

Ce projet de modification fera l’objet d’un commentaire ultérieur.

Quoi qu’il en soit, il n’en demeure pas moins que la procédure judiciaire relative à la notification de l’indu se rigidifie au bénéfice des caisses d’assurance maladie et au détriment des établissements de santé. Dans le même temps, le ministère fait mine de relâcher la bride sur la procédure de sanction financière. La « négociation » avec les acteurs sanitaires autour de cette réforme sera déterminante dans les prochaines semaines.

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