人工智慧在健保醫療費用審查之應用：自動化行政處分的法律挑戰與責任歸屬【本期企劃】 試閱
Application of Artificial Intelligence in NHI Medical Claim Reviews: Legal Challenges and Liability of Automated Administrative Acts
隨著人工智慧技術發展，健保署已運用自然語言處理模型輔助費用審查。然而，當 人工智慧的功能從「輔助決策」轉向「自動化行政處分」時，其法律定位、正當程序及責任歸屬面臨嚴峻挑戰。本文探討應用人工智慧於健保核刪之現況，分析將其用於高權行為之合適性，並指出演算法黑箱對行政處分理由說明義務的困境。本文主張應建立「以人為本」的審查機制與救濟途徑，確保人工智慧在提升效能之餘，亦能兼顧醫療專業裁量與受處分人之權益保障。
With the rapid advancement of artificial intelligence (AI), the National Health Insurance Administration, Ministry of Health and Welfare (NHIA) has utilized Natural Language Processing(NLP) models to assist in medical claim reviews. However, the transition of AI’s role from “decision support” to “automated administrative acts” poses significant legal challenges. This article explores the current application of AI in NHI reviews, analyzes its appropriateness as a sovereign power, and highlights the “black box” dilemma regarding the obligation to provide reasons for administrative acts. Finally, this article advocates for a “human-centered” review mechanism and effective remedies to ensure that AI balances efficiency with the protection of professional judgment and stakeholders’ rights.
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