行政监管与协议管理是当前医保基金监管的两大方式。实践中,针对定点医药机构既违约又违法的行为,行政处理与协议处理的界限尚存模糊之处,理论层面对行政协议违约责任与行政处理的协调问题研究有待深入,导致两者在适用与衔接上存在困境。本文以北京市2025年医保协议及实施细则为切入点,多维度比较二者差异、联系与适用场景。以法律视角,结合北京实践案例,剖析行政协议违约责任的权力来源、程序要求与内容设定,从震慑程度与错误成本等方面探讨两者的适用与衔接机制。通过“职责定位+基本原则+衔接机制”三重路径,明确医保行政部门与经办机构的职责定位,从处理方式和违规情形两方面把握基本原则,立足实践,细化行政处理与协议处理的衔接机制,完善程序衔接与配套保障措施。

Administrative supervision and agreement management are the two major approaches to the supervision of medical insurance funds at present. In practice, for the behaviors of designated medical and pharmaceutical institutions that are both in breach of contract and in violation of the law, the boundaries between administrative handling and contractual handling remain ambiguous. The theoretical research on the coordination of liability for breach of administrative contracts and administrative handling is still insufficient, leading to difficulties in their application and connection. This article takes the medical insurance agreement and its implementation details of Beijing City in 2025 as the entry point, and conducts a multi-dimensional analysis of differences, connections, and applicable scenarios between the two. From a legal perspective, combined with practical cases in Beijing City, it analyzes the power source, procedural requirements, and content setting of liability for breach of administrative contracts, and discusses the application and connection mechanism of the two from aspects such as the degree of deterrence and error cost. Through three paths of "duty positioning plus basic principles plus connection mechanism", it clarifies the duty positioning of medical insurance administrative departments and handling institutions, grasps the basic principles from the aspects of handling methods and violation situations, and based on practice, refines the connection mechanism of administrative handling and contractual handling, and improves supporting measures.