Nurses in private practice angry: they firmly oppose the billing system for infusions imposed by health insurance

For several months, a major crisis has shaken the liberal nursing care sector in France. Independent nurses, key players in home care, express growing opposition to a unilateral reform imposed by Health Insurance regarding perfusion coding. This decision, introduced without genuine consultation, undermines compensation for acts that are nonetheless complex, leading to a palpable conflict between Health Insurance and nursing unions. At the intersection of health issues, professional recognition, and continuity of care, this tension reveals flaws in the organization of the French healthcare system, with direct repercussions on the quality of home-based care.

The protest particularly revolves around the limitation imposed on billing for perfusion acts, which has become a structural element in the work of independent nurses. This regulatory change, which restricts coding to a single long perfusion per day (AMI 14), even with multiple separate prescriptions, is seen as a drastic regression. Unions like the National Union of Independent Nurses (Sniil) and Convergence Infirmière sharply criticize an administrative inconsistency that masks on-the-ground realities, risking to compromise access to care and deepen regional inequalities.

At the heart of this controversy is a delicate balance between controlling healthcare costs and adequately valorizing the nursing profession. On the eve of crucial contractual negotiations, unions are calling for an immediate moratorium on current decisions, also highlighting a local drift of the Primary Health Insurance Funds (CPAM) in some regions, with arbitrary tariff cuts fragmenting national coverage. The issue goes beyond mere coding: it concerns the recognition of the fundamental role of independent nurses in the care chain, especially in managing chronic conditions and post-hospitalization discharges. A new mobilization is expected to grow stronger, symbolizing a profession determined to protect its scope of practice and, by extension, the quality of care provided to patients at home.

Deep reasons for the conflict between independent nurses and Health Insurance

The conflict between independent nurses and Health Insurance stems from the recent unilateral management of perfusion coding, a procedure deemed essential by the profession. For over ten years, the coding of perfusion acts has been governed by stable rules, integrated into the General Nomenclature of Professional Acts (NGAP). However, in June, a circular from the National Health Insurance Fund (CNAM) disrupted this balance by limiting billing to a single long perfusion (AMI 14) per day, regardless of the actual number of prescribed and performed perfusions.

For independent nurses, this decision reflects a profound misunderstanding of the constraints and specificities of home nursing care. It is common for several separate perfusions to be administered at different times, requiring complete preparation each time. The imposed restriction effectively denies this double, or even triple, work without proper compensation.

Convergence Infirmière also criticizes the reduction in coding for specific acts such as moving from AMI 5 to AMI 4.1 in cases where perfusion is stopped within 24 hours, or changes in coding for continuous surveillance perfusions. These measures represent a regression that contradicts professional practices and the regulatory framework protecting nurses’ rights and the quality of care.

Numerical example: Until 2024, a nurse could bill two AMI 14 acts for two separate perfusions administered on the same day. Since the circular, this ceiling has been lowered to a single act per day, significantly impacting the professionals’ income.

This reform was implemented without genuine consultation with union representatives, although the National Federation of Nurses (FNI), Sniil, and Convergence Infirmière had initiated working groups with CNAM to clarify billing modalities within a consultative framework. This administrative standoff raises questions about governance and transparency in health policy management, highlighting an imbalance between budget control imperatives and the realities of care.

• Unilateral reduction of perfusion billing codes
• Failure to consider multiple distinct services
• Expected decrease in income for independent nurses
• Lack of prior dialogue with representative unions
• Consequences on the quality and organization of home care

Element	Before reform	After reform
Authorized billing per day	Multiple long perfusions (AMI 14)	A single long perfusion (AMI 14)
Billing for perfusion stop < 24h	AMI 5	AMI 4.1
Perfusion billing with continuous monitoring	AMI 14 and AMI 9	AMI 9 and AMI 4.1/2

To better understand this situation, it is helpful to consult up-to-date resources covering the protests of independent nurses and their demands, such as on CNews or L’Internaute.

The consequences of new regulations on the organization of home care

The imposition by Health Insurance of limited coding for perfusions is not merely a financial issue. It triggers a profound change in the functioning of home nursing care, especially for patients with chronic conditions or those discharged from hospitals. Indeed, (1) the complexity and frequency of perfusion acts are often underestimated, (2) the logistical and scheduling constraints for independent nurses are intensified, and (3) the sustainability of at-home care is threatened.

Nurses affected by these tariff cuts are naturally inclined to adapt their practices, which can lead to a reduction in quality or a decrease in interventions. Some professionals even express a desire to limit these services, threatening the availability of necessary care.

For patients, the impact is notably reflected in:

• 📌 Risk of postponements or cancellations of care ;
• 📌 Increased difficulties accessing specialized care ;
• 📌 Rise in unplanned hospitalizations ;
• 📌 Fragilization of personalized medical follow-up at home.

A field analysis conducted by the National Union of Independent Nurses highlights that some CPAMs have already prepared for the reform by locally applying tariff reductions without clear guidelines, generating a tariff inequality between territories. This raises concerns about care disparities and the risk of uneven care coverage depending on the patient’s location. These “local deviations” shed light on the lack of consistency in applying NGAP rules, with direct consequences for public health.

Direct consequences	Issues	Impacts
Reduced availability of independent nurses	Maintaining quality care	Risk of care access disruptions
Differentiated tariff cuts locally	System standardization	Increased territorial inequalities
Management difficulties for chronic conditions	Continuity of care	Less rigorous surveillance and control

Specialized platforms such as Infirmiers Libéraux en Colère detail these issues and offer support for affected professionals. National mobilization also includes public gatherings to raise awareness of this issue.

The role of nurses’ unions in contestation and defending independent nurses

Nursing unions play a central role in coordinating opposition to perfusion coding issues. Among them, the National Union of Independent Nurses (Sniil) and Convergence Infirmière are major actors in the conflict. These unions embody the collective voice of professionals, relaying their demands to national and local agencies of the Health Insurance.

Sniil, in particular, has expressed strong opposition by describing the CNAM circular as “not conforming to field realities” and categorically rejecting a decision imposed without consultation. The union demands a immediate moratorium on perfusion billing and calls for urgent genuine negotiations to establish a fair and transparent framework. The request also includes:

• 🟢 Respect for NGAP regulatory framework ;
• 🟢 Full recognition of the complexity of the care delivered ;
• 🟢 Guarantee of consistent application of rules across the country ;
• 🟢 Consideration of medical recommendations and tailored prescriptions ;
• 🟢 Reduction of unilateral arbitrations without prior consultation.

Convergence Infirmière aligns with this stance, emphasizing that this unilateral approach constitutes a true regression for the profession, endangering the home care offer. The unions call for increased mobilization, with national actions—demonstrations, strikes, and communication campaigns—that are intensifying.

A comprehensive overview of demands and actions is available via the official Sniil website Sniil Mobilization or on dedicated platforms. This fight is also relayed by specialized and national media such as Franceinfo.

Union	Main demands	Actions taken
Sniil	Immediate moratorium, NGAP compliance, negotiation	Demonstrations, strikes, campaigns
Convergence Infirmière	Withdrawal of circular, respect for care	Legal actions, mobilization

Examples of recent union mobilizations

• 📅 National demonstration in Paris and several cities on March 19, 2024
• 📅 Calls for strikes during the Paris 2024 Olympic Games
• 📅 Awareness campaigns on social media

The determination of unions illustrates the importance of combining the defense of professional interests and patient protection, in a context where medical demography and budget restrictions already weigh heavily on public health.

The economic and financial impact of coding changes for independent nurses

At the heart of the demands, the economic issues related to the new perfusion coding regulation are crucial. Compensation for independent nurses largely depends on billing precise acts codified in NGAP. When an act’s coding decreases, their overall income is directly affected, potentially leading to significant economic difficulties.

This situation is particularly critical because the profession requires not only technical skills but also investments in equipment, travel time, and administrative management. The tariff cuts, combined with unchanged or increased workload, create substantial financial pressure on nurses.

A comparative table summarizes the financial effects of the reform:

Indicator	Before reform	After reform	Financial impact 💶
AMI 14 billing (long perfusion)	Multiple billing	Single billing	Average loss of 20 to 30% of revenue related to perfusions
AMI 5 / AMI 4.1 billing (perfusion stop)	AMI 5	AMI 4.1	Approximate reduction around 10%
Preparation and travel costs	Not additionally valued	Not valued	Same cost, decreased profitability

This economic deterioration raises questions about the viability of the liberal practice and may even increase the risks of medical and paramedical desertification in certain rural areas.

Some key financial issues for independent nurses include:

• 📉 Significant reduction in income from complex acts
• 📉 Decreased professional motivation
• 📉 Difficulty maintaining essential investments
• 📉 Risk of premature departure or cessation of activity
• 📉 Increased territorial inequalities in access to care

Some professionals also analyze that a financial model ignoring the particularities of home care hampers the overall effectiveness of the healthcare system, a factor to consider in current debates about the future of city medicine. The interdependence between pricing, caregiver availability, and quality of care is a major issue requiring a concerted revision.

Justice and possible remedies against the unilateral decision of the Health Insurance

Faced with a decision imposed without negotiation, independent nurses and their unions are now considering legal actions to contest the perfusion coding reform. The legal and regulatory framework, notably NGAP, forms the basis of these claims.

The main argument concerns the non-respect of procedures and mandatory consultation in implementing tariff changes. Several remedies are considered:

• ⚖️ Filing with administrative courts to annul the circular ;
• ⚖️ Request for an injunction for an immediate moratorium on billing ;
• ⚖️ Quick proceedings to stop local arbitrary tariff reductions ;
• ⚖️ Intervention with the Higher Council of Territorial Public Service and other regulatory bodies.

Beyond technical aspects, the symbolic dimension is strong: it aims to guarantee the place of nursing care in city medicine and to preserve the quality of home care, at a time when these services are already regarded as indispensable. The rising tensions reflect a clear imbalance that only determined action could restore.

Type of remedy	Objective	Expected result
Administrative courts	Cancellation of circular	Suspension or abolition
Judicial référé	Block local tariff cuts	Ensure uniformity
Regulatory authorities	Respect for the consultation procedure	Reopen negotiations

This legal step must be accompanied by renewed dialogue to avoid a harmful escalation for all. The theme of this contestation is also shared on several specialized platforms, notably Aide BTS Assurance, which studies the legal protection of health professionals.

The central role of independent nurses in the healthcare system and the importance of their recognition

Beyond contractual and financial aspects, this conflict highlights the crucial role of independent nurses in the care pathway. They constitute an indispensable link in outpatient medicine and are also a primary actor in controlling public expenditure through reducing excessive hospitalizations.

Independent nurses provide daily:

• 🩺 Continuity of home care for chronic patients ;
• 🩺 Management of complex care, including medicated perfusions ;
• 🩺 Coordination with prescribing physicians for personalized follow-up ;
• 🩺 Adaptation of technical gestures to specific patient situations ;
• 🩺 Therapeutic education and complication prevention.

The recognition of their work, both in terms of pricing and administrative recognition, is a major challenge to guarantee an effective and humane health system. The restriction on perfusion coding weakens this recognition and risks discouraging professionals already confronted with the hardships of their job, such as managing schedules, travel, and administrative burdens.

Criterion	Importance for the system	Consequence of under-evaluation
Role in managing chronic diseases	Key for reducing hospitalizations	Increased hospital costs
Technical skills	Ensure safety and quality	Risks to care quality
Coordination with other professionals	Ensures a coherent care pathway	Dysorganization and follow-up disruptions

Publications like Le Point also highlight growing interprofessional tensions, reinforced by unconsulted regulatory evolutions. Recognizing independent nurses therefore appears as a crucial challenge for healthcare system cohesion.

Expectations and prospects of professionals ahead of contractual negotiations

With upcoming contractual negotiations, independent nurses and their union representatives are formulating several major demands to redefine the modalities for coding perfusions and related acts fairly and equitably.

Main demands are organized around:

• 🎯 Immediate withdrawal of regressive measures imposed by the circular ;
• 🎯 Establishment of a negotiated and transparent framework involving the Nursing Union and other concerned actors ;
• 🎯 Consideration of field realities and multiple distinct prescriptions ;
• 🎯 Guarantee of uniform application of rules nationwide to prevent tariff inequities ;
• 🎯 Better valuation of specific skills related to perfusions and nursing surveillance.

Without these guarantees, the risk of ongoing conflict and social tensions is real. The success of these negotiations is eagerly awaited as a strong indicator of the city medicine’s ability to maintain its attractiveness and quality.

Demand	Implication	Objective
Withdrawal of circular	Restore confidence	Launch fair negotiations
Open dialogue	Effective consultation	Consider field realities
Rule uniformity	Territorial equity	National harmonization
Professional valuation	Adjusted remuneration	Recognition of the profession

To deepen understanding of the issues and follow this mobilization’s progress, various resources are accessible, such as Le Monde Santé or dedicated union platforms.

National mobilization: actions, demonstrations, and calls for strike

In response to the impasse caused by the unilateral decision of the Health Insurance, the mobilization of independent nurses has intensified nationwide. Several actions have been undertaken, with the support of unions and a collective representing the profession, to denounce tariff injustice and demand respectful dialogue considering professional realities.

The main forms of mobilization include:

• 🚩 National and regional demonstrations in major cities 🇫🇷 ;
• 🚩 Calls for strikes during major events such as Paris 2024 ;
• 🚩 Gatherings in front of the Health Insurance agencies ;
• 🚩 Awareness campaigns on social networks and media ;
• 🚩 Media and legal actions to put pressure on authorities.

These movements aim to raise awareness among public authorities about the impact of decisions made without consultation, and to defend a care model that respects both human and economic aspects. While some actions have gained national visibility, discussions remain tense.

Type of action	Date	Objectives	Results
National demonstration	March 19, 2024	Restate demands, exert political pressure	Major mobilization, media coverage
Strike during Paris 2024	July – August 2024	Media visibility, support for dialogue	Impact on event coverage
Information campaigns	Ongoing	Inform the public and patients	Greater social understanding

To discover more details about the mobilization, it is possible to explore RMC BFMTV Santé or La Ruche des IDEL.

Consultation and prospects for better regulation of perfusion coding

Will the current contestation lead to a more constructive dialogue? The question remains open, but several signals suggest a need to reevaluate current modalities. The National Federation of Nurses, Sniil, and Convergence Infirmière emphasize the importance of broad consultation involving all stakeholders: professionals, physicians, health authorities, and users.

A meaningful consultation should be based on:

• 🔄 An in-depth assessment of home perfusion practices ;
• 🔄 Consideration of multiple and separate prescriptions ;
• 🔄 Harmonization of billing procedures at the national level ;
• 🔄 Establishment of a precise and stable framework respecting NGAP ;
• 🔄 Rigorous monitoring of economic and health impacts of the regulation.

A key point is recognizing the role of independent nurses not only as executors but as partners in outpatient medicine. In this perspective, coding must reflect the reality of technical, human, and organizational complexity of care. Discussions should also incorporate lessons learned from real situations to avoid new arbitrary measures.

Consultation axes	Objectives	Expected benefits
Assessment and audit	Understand field realities	Appropriate responses
Practice harmonization	National uniformity	Fairness and coherence
Multistakeholder dialogue	Broader consensus	Permanence of agreements
Professional valuation	Economic support	Motivation and retention

It will be necessary to monitor the evolution of this issue across various information platforms and union tracking sites such as Infirmiers.com. The success of a fair reform depends on this essential step.

FAQ: key questions about perfusion coding and issues for independent nurses

• ❓ Why is perfusion coding so important for independent nurses?
  The coding determines the remuneration of performed acts, reflecting their complexity and the time required to carry them out. Inadequate coding leads to financial loss and devaluation of professional skills.
• ❓ Who are the main unions involved in this protest?
  The National Union of Independent Nurses (Sniil) and Convergence Infirmière are leading this mobilization, representing the majority of concerned professionals.
• ❓ What are the possible consequences of the reform for patients?
  A reduction in services may lead to decreased access to home care, increasing risks of complications and unnecessary hospitalizations.
• ❓ Are there any legal remedies against the Health Insurance’s decision?
  Yes, several remedies are being considered, including filing with administrative courts and requesting suspension of measures pending negotiated agreement.
• ❓ How can I follow updates on this mobilization?
  Reliable sources include the official Sniil website (sniil.fr) and the platform Infirmiers Libéraux en Colère.

Source: www.espaceinfirmier.fr