医保契约法律制度研究

发布时间：2018-08-17 11:15

【摘要】：医保契约,即医保协议,是指基本医疗保险经办机构(简称医保机构)为实现对被保险人的医疗服务给付,而与医疗机构及医药零售机构签订的协议。医保契约是实施基本医疗保险的基本方式,是规范医保机构与医疗机构(包括医药零售企业)关系的主要载体,对维护基本医疗保险之被保险人正当利益与权利,规范医疗机构的医疗供给行为,促进医保服务水平的提高,推动我国基本医疗保险乃至整个医疗卫生制度的发展,具有非常重要的意义。然而,理论上对医保契约尚缺乏研究,实践中对医保契约的认识比较混乱,制度上也未构建起基本的医保契约规则,不仅对当下医保制度的实施构成不利影响,更是医保制度长远健康发展的内在障碍。本文基于对我国基本医保运行的长期观察,在充分调查研究的基础上,分析了医保契约的法律属性,提出取消现存的定点管理制度实施契约管理,并对医保机构的监管权与契约权、医保契约中权利义务的配置、订立与履行、被保险人权益保护、争议的法律救济等医保契约法律制度进行了较为全面的研究,根据我国的国情和现实状况以及我国基本医疗保障制度的发展趋势,对医保契约的诸多问题提出了建设性意见。
[Abstract]:Medical insurance contract, that is, medical insurance agreement, refers to the basic medical insurance agency (referred to as medical insurance agency) to realize the medical service payment to the insured, and the agreement signed with the medical organization and the pharmaceutical retail organization. Medical insurance contract is the basic way to implement basic medical insurance, it is the main carrier of standardizing the relationship between medical insurance institution and medical institution (including medical retail enterprise), and it can safeguard the legitimate interests and rights of the insured of basic medical insurance. It is of great significance to standardize the medical supply behavior of medical institutions, to promote the improvement of medical service level, and to promote the development of basic medical insurance and even the whole medical and health system in China. However, there is still a lack of research on the medical insurance contract in theory, the understanding of the medical insurance contract is confused in practice, and the basic medical insurance contract rules have not been constructed in the system, which not only has a negative impact on the implementation of the current medical insurance system. It is also an inherent obstacle to the long-term and healthy development of the health insurance system. Based on the long-term observation of the operation of basic medical insurance in China, and on the basis of full investigation and research, this paper analyzes the legal attributes of medical insurance contract, and proposes to abolish the existing fixed-point management system to implement contract management. It also makes a comprehensive study on the legal system of medical insurance contract, such as supervision right and contract right of medical insurance organization, allocation of rights and obligations in medical insurance contract, establishment and performance, protection of insurant's rights and interests, legal remedy of dispute, etc. According to the situation and reality of our country and the development trend of our country's basic medical security system, this paper puts forward some constructive suggestions on many problems of medical insurance contract.
【学位授予单位】：西北大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：D922.182.3;D923.6

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