全民健康保險醫療服務審查與正當法律程序—兼評行政法院相關判決【本期企劃】 試閱
Medical Service Review under National Health Insurance and Due Process of Law: A Critical Analysis of Relevant Administrative Court Judgments
本文主要針對全民健康保險醫療服務審查程序與醫療服務費用核刪之法律性質與行政法院相關判決，進行分析與評釋。從憲法對於財產權基本權利保障所衍生的「組織與程序保障功能」來檢驗，保險人與保險醫事服務機構雖然成立行政契約之法律關係，但其醫療服務費用給付仍受到全民健康保險法以及其所授權之法規命令嚴格拘束，且醫療服務費用既受到財產權所保障，因此其核刪決定應受「正當行政程序」之拘束，保險人仍應依職權調查原則進行行政調查，而非完全由保險醫事服務機構就保險人之錯誤決定負舉證責任。本文並提出全民健康保險醫療服務審查程序之法規修正方向建議，以落實和強化正當行政程序、平衡保險人與特約醫事服務機構之利益及緩解彼此不信任的緊張關係。
This article analyzes and evaluates the legal nature of the medical service review process and the reduction of medical expenses under the National Health Insurance (NHI) system, as well as the relevant judgments of the Administrative Court. From the perspective of the “organizational and procedural protection function” derived from the constitutional protection of property rights, this study examines the insurer’s strict adherence to the National Health Insurance Act and its authorized administrative regulations. Although the insurer and the healthcare service providers have entered into an administrative contract, the payment of medical service fees remains protected under the fundamental right to property. Consequently, any decision regarding the reduction of such fees must be bound by the “due administrative process.” The insurer is obligated to investigate evidence ex officio (according to the principle of ex officio investigation), rather than placing the entire burden of proof on the healthcare service providers to contest the insurer’s erroneous decisions. Finally, this article proposes directions for legal amendments to the NHI medical service review procedures. The aim is to implement and strengthen due administrative process, thereby balancing the conflict of interest between the insurer and contracted healthcareproviders, and alleviating the tension caused by mutual distrust.
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