在第三人侵权案件中,医保基金先行支付后难以向侵权人追偿,是医保运行中亟待解决的实践性难题。本文从法理学视角出发,从社会观念、系统衔接、制度运行三个层面分析这一困境的形成原因。追偿失灵并非单一环节的问题,而是参保人告知义务虚化、先行支付制度休眠、行政追偿无力三重障碍叠加的结果。究其根源,公众对医保基金“社会共担”属性的认知尚未形成,司法部门与医保部门之间缺少有效的信息对接机制,规则设计与真实的就医和诉讼场景存在脱节。破解这一困局,需要推动公众认知从个体福利向社会共担转变,建立法院、检察院、医保部门三方协同的工作机制,打通信息共享与程序衔接的堵点,同时完善医保基金追偿的内部闭环管理及信用惩戒等配套措施。医保基金追偿权的有效实现,有赖于弥合“书本上的法”与“行动中的法”之间的鸿沟。

A critical practical challenge in the operation of medical insurance is the difficulty in recovering advanced payments from tortfeasors in third-party tort cases. From a jurisprudential perspective, this paper analyzes the causes of this dilemma across three dimensions: social perceptions, systemic coordination, and institutional operation. The failue of recovery is not a problem of a single link, but the result of a triple overlap: the weakening of the insured's duty to disclose, the dormancy of the advance payment system, and the ineffectiveness of administrative recovery. At the root of the problem lies the public's insufficient awareness of the “social risk-sharing” nature of the medical insurance fund, the lack of effective information exchange mechanisms between judicial authorities and healthcare security administrations, and the disconnect between rule design and the realities of medical treatment and litigation. To solve this dilemma, it is necessary to promote a shift in public perception from individual welfare to social risk-sharing, establish a collaborative working mechanism among courts, procuratorates, and healthcare security administrations, remove blockages in information sharing and procedural coordination, and improve internal closed-loop management of recovery along with supporting measures such as credit sanctions. The effective realization of the medical insurance fund's right of recovery depends on bridging the gap between “law in books” and “law in action”.