論健保署停止特約之行政行為性質──以司法院釋字第753號解釋為中心

中央健康保險署與醫事服務機構間之全民健康保險特約醫事服務機構合約關係存續中，特約機構若「以不正當行為或以虛偽之證明、報告或陳述，申報醫療費用」，健保署除得依全民健康保險法處以罰鍰、公告名稱及違法事實外，亦得依全民健康保險醫事服務機構特約及管理辦法「停止特約」。上開健保署所為「停止特約」，民國95年7月18日最高行政法院95年7月份庭長法官聯席會議（二）決議認係行政處分。106年10月6日司法院公布釋字第753號【全民健保特約之違約處置案】解釋，則認「停止特約」等行政行為係違約之處理，宣告特管辦法有關規定具有健保法授權，未違反憲法法律保留與法律授權明確性原則，足見並非認停止特約係行政處分。本文認為，特管辦法停止特約規定係定型化契約，透過轉引成為約款，於他造違約時發生債務不履行約定損害賠償責任，性質係行政契約形成權或抗辯權之意思表示，非行政處分。停止特約不得對非特約當事人之醫事人員主張，透過雙方合意和解，另締結債務變更契約，自得恢復效力。停止特約規定與憲法法律保留原則間之關係，考量健保涉及公益，除對特約機構限制工作權與財產權外，亦間接影響被保險人財產權與健康權，審查應兼由除外說及授權說立論，較為周延。惟無論依何說，並無違反憲法。停止特約基於以上，性質實為行政契約，如此方與司法院釋字第753號解釋意旨相符，有關實務應檢討改進，上開最高行政法院決議須儘速不再援用，以免遭受違憲質疑。

During the insurance service rendering contract between medical care institutions and National Health Insurance (NHI) Administration is effective, if the institutions“apply for reimbursements or claims medical expenses through improper conduct, or makes false certification, report, misrepresentation”, NHI Administration can impose a fine or also announce the name and the nature of the violation according to NHI Act, in addition to suspend the contract abovementioned according to Regulations Governing Contracting and Management of NHI Medical Care Institutions (Contracting and Management Regulations). As to this official request of suspension by NHI Administration, the Resolution (b) of Joint Meeting of the Supreme Administrative Court dated July 18, 2006, decided it is an administrative act. But the Interpretation no.753【Measures Regulating Breach of Contract Under the National Health Insurance Act Case】of the Judicial Juan dated October 6, 2017, described it is an administrative dealing with breach of contract, declared the Contracting and Management Regulations is consistent with principle of legal reservation and clarity and definiteness of statutory authorization in Constitutional Law. It can well perceive that the Interpretation no.753 of Judicial Juan does not consider the official request is an administrative act. This article believes that the suspend contract provision in Contracting and Management Regulations are standardized contracts, when parties of the contract both agreed and signed, the provision become a terms and clauses of the contract. When adverse party breach the contract, it should burden the liquidated liability for damages of non-performance of debt obligation, so the contract suspension request is an administrative contractual manifestation to format contract or exception of reimbursement, not an administrative act. The contract suspension request cannot claim to medical personnel as they are non-contract party, and the contract can be reinstated by settlement agreement of debt modification by contractual parties’mutual assent. About whether the contract suspension request provision corresponds with principle of legal reservation in Constitutional Law, considering the NHI involves public welfare, it not only restricts the right to work and the right to property of contracted medical care institutions, it also indirectly affects the right to property and the right to health of the insured. The review should base on both the exception theory and the authorization theory, hence will be more comprehensive. But no matter according to what theory, it does not violate the Constitutional Law. In summary, the contract suspension request based on the above argumentations is an administrative contract actually therefore is consistent with the intention of the Interpretation no.753 of the Judicial Juan. Relevant practices should be corrected and improved, and the Resolution (b) of the Supreme Administrative Court must be no longer invoked as soon as possible to avoid being challenged as unconstitutional.