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국민건강보험의 행정법적 쟁점
Current Issues on National Health Insurance from the Perspective of the Administrative Law

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Authors
최계영
Issue Date
2014-06
Publisher
서울대학교 법학연구소
Citation
법학, Vol.55 No.2, pp. 43-72
Keywords
National Health Insuranceoutpatient prescriptioncriteria for medical care benefitscollection of unjust enrichment국민건강보험원외처방요양급여기준부당이득징수처분
Abstract
현행 국민건강보험 제도의 법률관계는 기본적으로 행정법적 법률관계라고 해도 과언이 아니다. 국가는 보험자인 국민건강보험공단과 심사자인 건강보험심사평가원을 각각 공법인 형태로 설립하였고, 보험급여의 심사와 지급에 관한 권한을 행정처분의 형식으로 행사하게끔 하였다. 또한 모든 국민과 모든 의료기관을 원칙적으로 피보험자와 요양기관이 되도록 하고, 의료행위의 허용범위도 고시와 같은 행정입법으로 규정하고 있다. 이 글의 목적은 국민건강보험 제도를 구성하는 행정조직과 행정작용에 대해 행정법학자의 입장에서 전반적으로 설명하고자 하는 데 있다. 이 글에서는 국민건강보험의 기본구조를 살펴본 후, 요양급여의 대상과 비용의 기준을 정하는 행정입법과 요양급여비용을 통제하여 보험재정의 건전성을 확보하기 위한 행정처분을 검토하였다. 그리고 그 과정에서 과잉 원외처방 등 현안이 되고 있는 쟁점에 대해서도 함께 살펴보았다. 마지막으로 요양급여기준을 정하는 고시와 관련된 문제를 별도로 검토하였다. 이러한 고시는 행정입법과 행정행위의 성격을 함께 가지고 있기 때문에 기존의 일반행정법 이론으로는 해결하기 어려운 여러 가지 새로운 문제를 야기한다.
It is not too much to say that the legal relations in the current national health insurance system are basically administrative law-based legal relations. The government established the National Health Insurance Corporation as an insurer and the Health Insurance Review & Assessment Service as a reviewer in the form of public juristic persons and allowed them to exercise authorities regarding the review and payment of insurance benefits in the form of administrative dispositions. In addition, the government stipulated that all people and all medical institutions should be policyholders and medical care institutions respectively in principle and also stipulated the permissible range of medical practices by means of statutory instruments such as ordinances. The purpose of this writing is to generally explain the administrative organizations and administrative actions that constitute the health insurance system from the position of an administrative law scholar. In this writing, the basic structure of the national health insurance was examined and, thereafter, statutory instruments that determine the beneficiaries of medical care benefits and the criteria for expenses and administrative acts intended to control medical care benefit costs in order to secure the soundness of insurance finance were reviewed. In addition, pending issues such as excessive outpatient prescriptions were also reviewed in the course. Finally, problems related to the ordinances that determine the criteria for medical care benefits were separately reviewed. Since these ordinances have both the natures of statutory instruments and administrative acts, they cause various new problems that cannot be easily solved with existing general administrative law theories.
ISSN
1598-222X
Language
Korean
URI
http://hdl.handle.net/10371/92655
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College of Law/Law School (법과대학/대학원)The Law Research Institute (법학연구소) 법학법학 Volume 55, Number 1/4 (2014)
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