CN107657376A - Commercial health insurance insurance fraud risk control system and method - Google Patents
Commercial health insurance insurance fraud risk control system and method Download PDFInfo
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- CN107657376A CN107657376A CN201710879091.4A CN201710879091A CN107657376A CN 107657376 A CN107657376 A CN 107657376A CN 201710879091 A CN201710879091 A CN 201710879091A CN 107657376 A CN107657376 A CN 107657376A
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- G06Q10/0635—Risk analysis of enterprise or organisation activities
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- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
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Abstract
The invention discloses a kind of commercial health insurance insurance fraud risk control system and method, the system includes request message receiving module, request message parsing module, Shang Bao companies identification module, request message package module, request message sending module, result packet parsing module, result message assembling module and result message and returns to module.The present invention solves the problems, such as that hospital side's transmission information needed for each business's guarantor's Corporation system and its different business does not have unified message format, possesses the ability that more different business protect the processing of Corporation system differentiation datas；The message format of hospital information system HIS requests is unified；The data protected to hospital and business between Corporation system have carried out intelligent conversion, improve terseness, the ease for use of passage so that interaction is more smooth, safe efficient.
Description
Technical field
The present invention relates to internet medical information technical field, in particular to a kind of commercial health insurance insurance fraud risk control
System and method.
Background technology
Commercial health insurance is the important component of China's health security system, accelerates the development of commercial health insurance,
Be advantageous to tamp multi-level health security system, meet the diversified health care demand of the people.At this stage, business health
The compensation of insurance with medical institutions mainly by, manually come what is completed, not docked under line, can not get doctor in time
Treat the move back expense data of mechanism.If patient is in commercial insurance company's (abbreviation：Shang Bao companies) Claims Resolution after the completion of, to medical institutions Shen
Please move back expense, then be easy to occur insurance fraud behavior.The compensation cost increase of insurance company had so both been caused, has also been unfavorable for business and protects public affairs
Take charge of the actuarial analysis and product design to insurance products.At present, it is how logical by being settled a claim on line in the case of patient's move back expense
Road, solve the problems, such as insurance fraud, be exactly our urgent need to resolve the problem of.
The content of the invention
For in the prior art the defects of, the invention provides a kind of commercial health insurance insurance fraud risk control system, wound
Related air control model is built, the function of insurance fraud monitoring is provided for insurance company.
To achieve the above object, the commercial health insurance insurance fraud risk control system designed by the present invention, its special character
It is, including healthy business insurance access platform, basic data module, air control rule configuration module and air control handle mould in real time
Block；
The healthy business insurance access platform：For being docked with hospital information system, subscriber identity information and report are gathered
Sell cost information；
The basic data module：For the subscriber identity information and information of submitting an expense account to be pre-processed and deposited
Storage；
The air control rule configuration module：For configuring business insurance antifraud rule；
The air control real-time processing module：Can for the insurance fraud according to the business insurance antifraud rule judgment user
Energy property, when the insurance fraud possibility is more than risk probability threshold values, protects Corporation system to business and send the alarm of insurance fraud risk.
Further, business insurance antifraud rule includes several monitoring dimensions in the air control rule configuration module,
And threshold values, the accounting of each monitoring dimension.
Further, the monitoring dimension includes time interval, the reimbursement frequency, hospital's quantity, insurance company's quantity.
Further, the air control real-time processing module includes frequency inquiry, hospital is inquired about, insurance company inquires about, deceived
Protect and differentiate and insurance fraud five submodules of alarm；
The frequency, which is inquired about in the time interval set for inquiring about the user, occurs the number of move back expense, and result is sent
Differentiate to insurance fraud；
The hospital is inquired about in the time interval set for inquiring about the user occurred move back expense behavior in a how many hospital,
And result is sent to insurance fraud and differentiated；
The insurance company is inquired about in the time interval set for inquiring about the user to be occurred in a how many insurance company
Move back expense behavior, and result is sent to insurance fraud and differentiated；
The insurance fraud differentiates for being inquired about according to the frequency, result and the monitoring dimension that hospital is inquired about, insurance company's inquiry is sent
Each threshold values contrast of monitoring dimension, calculates insurance fraud possibility, when the insurance fraud possibility is more than threshold values, then sends out result in degree
Deliver to insurance fraud alarm；
The insurance fraud is alerted for differentiating that the warning content sent protects Corporation system to business and sends insurance fraud alarm according to insurance fraud.
A kind of method based on above-mentioned commercial health insurance insurance fraud risk control system, it is characterized in that, including such as
Lower step：
1) business insurance antifraud rule is set, and is configured at air control rule configuration module；
2) business insurance access platform gathers subscriber identity information and information of submitting an expense account by hospital information system, concurrently
Deliver to basic data module；
3) the basic data module carries out pretreatment storage to the information of submitting an expense account of the user；
4) air control real-time processing module is according to the insurance fraud possibility of the business insurance antifraud rule judgment user, when
When the insurance fraud possibility is more than risk probability threshold values, the alarm of insurance fraud risk is sent；
5) insurance fraud risk is alerted and warning content notifies Shang Bao companies.
Preferably, the business insurance antifraud rule includes the interior user of the time interval of monitoring, the time interval
The frequency, hospital's quantity, Shang Bao companies quantity and the three's accounting of move back expense.
Preferably, the process of pretreatment includes in the step 3)：Information of submitting an expense account is filled a vacancy, replaced, data
Merge, data are split, data load and abnormality processing.
The invention provides a kind of commercial health insurance directly to pay for air control system online, and emphasis solves to receive doctor in business's platform of keeping tie
After the business's guarantor patient move back expense notice for treating mechanism, judge whether the case has insurance fraud risk according to existing data, the patient whether should
This pipes off.The present invention is protected by business and is uniformly accessed into platform, and dynamic setting business protects insurance fraud monitoring indices, and adjustment is every
Index proportion.By the monitoring to these indexs, reach the purpose for finding to differentiate that patient is deposited in the absence of insurance fraud.Energy of the present invention
Enough early warning patient's insurance fraud cases, remind insurance company to pay attention to possible insurance fraud personnel, reduce insurance company's associated loss.
Advantages of the present invention includes：
1) using patient identity of insuring as mark, dimension is set according to air control, counted as (such as the frequency, between the time in dimension
Every etc.) patient's move back expense number of insuring；
2) patient is set to cheat insurance fraud rule from multiple dimensions：Insure patient's move back expense time interval, it is settable to be less than or equal to
Some time interval, patient's move back expense frequency of insuring, it can be set and be more than or equal to some number etc.；
3) historical data inquired is contrasted with each dimension of air control rule, and comprehensive each dimension proportion, intelligence
It can judge whether patient has insurance fraud fraud；
4) according to the accurate early warning of risk rule of setting, insurance company's loss is reduced.
Brief description of the drawings
Fig. 1 is the structured flowchart of commercial health insurance insurance fraud risk control system of the present invention.
Fig. 2 is the flow chart of the method for commercial health insurance insurance fraud risk control system of the present invention.
Wherein：Healthy business insurance access platform 1, basic data module 2, air control rule configuration module 3 and air control are real-time
Processing module 4, hospital information system 5, business protect Corporation system 6.
Embodiment
Below in conjunction with the drawings and specific embodiments, the present invention is described in further detail.
As depicted in figs. 1 and 2, a kind of commercial health insurance insurance fraud risk control system of the present invention, including：Healthy business is protected
Dangerous access platform 1, basic data module 2, air control rule configuration module 3 and air control real-time processing module 4.The present invention is based on calculating
Machine and communication network, which are realized, uses Java2EE platforms, by calling HTTP interface request and hospital HIS system and business insurance public
Department's system communication connection.
Healthy business insurance access platform 1：For being docked with hospital information system 5, subscriber identity information and reimbursement are gathered
Cost information.Healthy business insurance access platform 1 is multiple, is realized respectively by the PC installed in each hospital.
Basic data module 2：For subscriber identity information and information of submitting an expense account to be pre-processed and stored.Pretreatment
Process include：Information of submitting an expense account is filled a vacancy, replaced, data merge, data are split, data load and abnormality processing.
Air control rule configuration module 3：For configuring business insurance antifraud rule.If business insurance antifraud rule includes
Dry monitoring dimension, and the threshold values of each monitoring dimension, accounting.Monitoring dimension includes time interval, the reimbursement frequency, hospital's number
Amount, insurance company's quantity.
Air control real-time processing module 4：For the insurance fraud possibility according to the business insurance antifraud rule judgment user, when
When insurance fraud possibility is more than risk probability threshold values, the alarm of insurance fraud risk is sent to commercial insurance company's system 6.
Air control real-time processing module 4 includes frequency inquiry 41, hospital's inquiry 42, insurance company's inquiry 43, insurance fraud discriminating 44
45 5 submodules are alerted with insurance fraud；
The frequency inquiry 41 be used for inquire about the user setting time intervals in occur move back expenses numbers, and by result send to
Insurance fraud differentiates 44；
Hospital's inquiry 42 is used to inquire about in the time interval of user setting occurred move back expense behavior in a how many hospital, and
Result is sent to insurance fraud and differentiates 44；
Insurance company's inquiry 43 is used to inquire about in the time interval of user setting to be occurred to move back in a how many insurance company
Take behavior, and result is sent to insurance fraud and differentiates 44；
Insurance fraud differentiates 44 result and the prisons for being used to send according to frequency inquiry 41, hospital's inquiry 42, insurance company's inquiry 43
The threshold values contrast of each monitoring dimension in dimension is controlled, calculates insurance fraud possibility, when insurance fraud possibility is more than threshold values, is then sent out result
Deliver to insurance fraud alarm 45；
Insurance fraud alarm 45 is used to differentiate that 44 warning contents sent protect Corporation system 6 by mail to each business according to insurance fraud
Send insurance fraud alarm.
A kind of method based on above-mentioned commercial health insurance insurance fraud risk control system, comprises the following steps：
1) business insurance antifraud rule is set, and is configured at air control rule configuration module 3.
Business insurance antifraud rule include the time interval of monitoring, the frequency of user's move back expense in the time interval,
Hospital's quantity, Shang Bao companies quantity and three's accounting.Idiographic flow includes：
11) the move back expense lag rule of configuration monitoring：Such as the time of move back expense is within one week or January.
12) move back expense frequency alarm regulation is configured：The number that the frequency of move back expense occurs in the time interval is more than or equal to A times.
13) configuration is related to move back expense hospital quantity alarm regulation：In the time interval of setting, the quantity of move back expense hospital is in B
Within family.
14) configuration is related to the quantity alarm regulation of move back expense insurance company：In the time interval of setting, what move back expense was related to
The quantity of insurance company is within C family.
15) frequency dimension accounting a% is configured, configuration is related to hospital quantity dimension accounting b%, configuration is related to insurance company's number
Measure dimension accounting c%.
A, B, C, a, b, c are natural number.
2) business insurance access platform 1 gathers subscriber identity information and information of submitting an expense account by hospital information system 5, and
Send to basic data module 2.Idiographic flow is：
21) business insurance access platform 1 gathers subscriber identity information and information of submitting an expense account by hospital information system 5；
22) subscriber identity information is compared business insurance access platform 1 with database information, and patient identity is protected to business
It is authenticated；
23) judge whether the user is business's warranty family, is to send subscriber identity information and information of submitting an expense account to base
Plinth data module 2, otherwise terminates.
3) basic data module 2 is pre-processed and stored to the information of submitting an expense account of the user.Basic data module 2
Required according to commercial insurance company, information of submitting an expense account is filled a vacancy, replaced, data merge, data are split, data load and different
Often processing.
4) air control real-time processing module 4 is according to the insurance fraud possibility of the business insurance antifraud rule judgment user, when deceiving
When guarantor's possibility is more than risk probability threshold values, the alarm of insurance fraud risk is sent.Idiographic flow is：
41) whether the number A that move back expense occurs for the patient that insures in the monitoring specific time interval of frequency inquiry 41 is more than threshold values,
If greater than threshold values, then value is 1；
42) whether the quantity B that move back expense hospital occurs for the patient that insures in the monitoring specific time interval of hospital's inquiry 42 is more than
Threshold values, if greater than threshold values, then value is 1；
43) the quantity C of move back expense insurance company occurs for the patient that insures in the monitoring specific time interval of insurance company's inquiry 43
Whether threshold values is more than, if greater than threshold values, then value is 1；
44) insurance fraud differentiates that 44 above patient occur the number A of move back expense, quantity B, Huan Zhefa of patient's generation move back expense hospital
The result that tri- dimensions of quantity C of raw move back expense insurance company are drawn, is multiplied by respective dimension proportion a%, b%, c%, finally
Obtain insurance fraud possibility result.
5) insurance fraud risk is alerted and warning content notifies business to protect Corporation system 6.Insurance fraud alarm 45 differentiates 44 according to insurance fraud
The warning content of transmission, warning information is sent to relevant people etc. by mail, reminds insurance company to pay attention to whether investigating patient
There is insurance fraud behavior.
First embodiment of the invention comprises the following steps：
A) Claims Resolution rule is set, setting insured patient within 15 days, and in Dan Jia hospitals, single insurance company is accumulative to be occurred
More than 5 move back expense (revocation clearing) behaviors, the proportion a% for setting the number A of patient's generation move back expense is 60%, the number of move back expense hospital
It is 20% to measure B proportions b%, and the proportion c% that the quantity C of move back expense insurance company occurs for patient is 20%.The valve of move back expense hospital is set
It is worth for 1, the threshold values of move back expense insurance company is 1, and the threshold values of move back expense stroke count is 5.
B subscriber identity information) is obtained：Mr. Wang, passport NO.：420111xxxxxxxx6439, carry out data encryption processing
And information is transmitted separately to Shang Bao companies.
C) when move back expense behavior (revocation clearing) occur for the patient Mr. Wang that insures, always inquire about, send out in business's insurance system historical data
Existing Mr. Wang is within nearest 15 days, in hospital N, in insurance company's first, 6 move back expense behaviors has occurred, therefore its insurance fraud may
1 × 20%+1 of behavior × 20%+1 × 60%=100%, therefore very big insurance fraud possibility be present in the patient；
D) insurance fraud alarm 45 sends warning information to related personnel, reminds insurance company to pay attention to paying attention to adjusting to the patient
Look into.
Comprise the following steps in second embodiment of the invention：
A) Claims Resolution rule is set, setting insured patient within 15 days, and in Dan Jia hospitals, 2 insurance companies are accumulative to be occurred
More than 6 move back expense (revocation clearing) behaviors, the proportion a% for setting the number A of patient's generation move back expense is 60%, the number of move back expense hospital
It is 20% to measure B proportions b%, and the proportion c% that the quantity C of move back expense insurance company occurs for patient is 20%.The threshold values of move back expense hospital is
1, the threshold values of move back expense insurance company is 2, and the threshold values of move back expense stroke count is 6.
B subscriber identity information) is obtained：Lee, passport NO.：420311xxxxxxxx7548, carry out data encryption processing
And information is transmitted separately to Shang Bao companies.
C) when move back expense behavior (revocation clearing) occur for the patient Mr. Wang that insures, always inquire about, send out in business's insurance system historical data
Within nearest 15 days in hospital Q, in insurance company's first and insurance company's second, 3 move back expense behaviors have occurred for existing Lee,
Therefore 1 × 20%+1 of its insurance fraud probable behavior × 20%+0 × 60%=40%, therefore the patient there is a possibility that insurance fraud is little, no
Give concern.
Above in association with most preferred embodiment, invention has been described, but the invention is not limited in implementation disclosed above
Example, and modification, equivalent combinations that the various essence according to the present invention are carried out should be covered.
The content not being described in detail in this specification belongs to prior art known to professional and technical personnel in the field.
Claims (7)
- A kind of 1. commercial health insurance insurance fraud risk control system, it is characterised in that：Including healthy business insurance access platform (1), basic data module (2), air control rule configuration module (3) and air control real-time processing module (4)；The healthy business insurance access platform (1)：For being docked with hospital information system (5), collection subscriber identity information and Submit an expense account information；The basic data module (2)：For the subscriber identity information and information of submitting an expense account to be pre-processed and stored；The air control rule configuration module (3)：For configuring business insurance antifraud rule；The air control real-time processing module (4)：Can for the insurance fraud according to the business insurance antifraud rule judgment user Energy property, when the insurance fraud possibility is more than risk probability threshold values, protects Corporation system (6) to business and send the alarm of insurance fraud risk.
- 2. commercial health insurance insurance fraud risk control system according to claim 1, it is characterised in that：The air control rule Business insurance antifraud rule includes several monitoring dimensions in configuration module (3), and each monitors the threshold values of dimension, accounts for Than.
- 3. commercial health insurance insurance fraud risk control system according to claim 2, it is characterised in that：The monitoring dimension Including time interval, the reimbursement frequency, hospital's quantity, insurance company's quantity.
- 4. commercial health insurance insurance fraud risk control system according to claim 3, it is characterised in that：The air control is real-time Processing module (4) includes frequency inquiry (41), hospital's inquiry (42), insurance company's inquiry (43), insurance fraud discriminating (44) and insurance fraud Alert (45) five submodules；The frequency inquiry (41) is used to inquire about the number that move back expense occurs in the time interval of user setting, and result is sent Differentiate (44) to insurance fraud；Hospital's inquiry (42) is used to inquire about in the time interval of user setting occurred move back expense behavior in a how many hospital, And result is sent to insurance fraud and differentiates (44)；Insurance company's inquiry (43) is used to inquire about in the time interval of user setting to be occurred in a how many insurance company Move back expense behavior, and result is sent to insurance fraud and differentiates (44)；The insurance fraud discriminating (44) according to the frequency for inquiring about (41), (42) are inquired about by hospital, insurance company's inquiry (43) is sent As a result the threshold values with each monitoring dimension in monitoring dimension contrasts, and insurance fraud possibility is calculated, when the insurance fraud possibility is more than valve Value, then result is sent to insurance fraud and alert (45)；The insurance fraud alarm (45) is used to differentiate that the warning content that (44) are sent sends insurance fraud alarm to Shang Bao companies according to insurance fraud.
- A kind of 5. method of the commercial health insurance insurance fraud risk control system based on described in claim 1, it is characterised in that：Bag Include following steps：1) business insurance antifraud rule is set, and is configured at air control rule configuration module (3)；2) business insurance access platform (1) gathers subscriber identity information and information of submitting an expense account by hospital information system (5), and Send to basic data module (2)；3) the basic data module (2) carries out pretreatment storage to the information of submitting an expense account of the user；4) air control real-time processing module (4) is according to the insurance fraud possibility of the business insurance antifraud rule judgment user, when When the insurance fraud possibility is more than risk probability threshold values, the alarm of insurance fraud risk is sent；5) insurance fraud risk is alerted and warning content notifies business to protect Corporation system (6).
- 6. the method for commercial health insurance insurance fraud risk control system according to claim 5, it is characterised in that：The business Industry insurance antifraud rule includes the frequency, hospital's quantity, business of the interior user's move back expense of the time interval of monitoring, the time interval Guarantor company quantity and three's accounting.
- 7. commercial health insurance according to claim 5 directly pays for intelligent recommendation method online, it is characterised in that：The step 3) process of pretreatment includes in：Information of submitting an expense account is filled a vacancy, replaced, data merge, data split, data loading and Abnormality processing.
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| Application Number | Priority Date | Filing Date | Title |
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| CN201710879091.4A CN107657376A (en) | 2017-09-26 | 2017-09-26 | Commercial health insurance insurance fraud risk control system and method |
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| CN201710879091.4A CN107657376A (en) | 2017-09-26 | 2017-09-26 | Commercial health insurance insurance fraud risk control system and method |
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| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN108985950A (en) * | 2018-07-13 | 2018-12-11 | 平安科技（深圳）有限公司 | Electronic device, user's insurance fraud method for prewarning risk and storage medium |
| CN109118353A (en) * | 2018-07-20 | 2019-01-01 | 中国邮政储蓄银行股份有限公司 | The data processing method and device of air control model |
| CN109272241A (en) * | 2018-09-29 | 2019-01-25 | 北京优全智汇信息技术有限公司 | One seed nucleus pays for method and apparatus |
| CN109493242A (en) * | 2018-10-30 | 2019-03-19 | 平安医疗健康管理股份有限公司 | Unit joining insurance's recognition methods and Related product |
| CN109559236A (en) * | 2018-10-27 | 2019-04-02 | 平安医疗健康管理股份有限公司 | The method and apparatus of drug reimbursement Information abnormity |
| CN109670974A (en) * | 2018-12-14 | 2019-04-23 | 中国平安人寿保险股份有限公司 | A kind of risk monitoring and control method and device, electric terminal |
| CN112767179A (en) * | 2021-01-11 | 2021-05-07 | 上海瀚之友信息技术服务有限公司 | Monitoring and early warning method and system for vehicle insurance value-added service |
| CN116308434A (en) * | 2023-05-12 | 2023-06-23 | 杭州大鱼网络科技有限公司 | Insurance fraud identification method and system |
| CN116307607A (en) * | 2023-03-24 | 2023-06-23 | 探保网络科技(广州)有限公司 | Insurance core system monitoring system and method |
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| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN108985950A (en) * | 2018-07-13 | 2018-12-11 | 平安科技（深圳）有限公司 | Electronic device, user's insurance fraud method for prewarning risk and storage medium |
| WO2020010712A1 (en) * | 2018-07-13 | 2020-01-16 | 平安科技（深圳）有限公司 | Electronic device, user insurance fraud risk pre-warning method, and storage medium |
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| CN109118353B (en) * | 2018-07-20 | 2022-03-15 | 中国邮政储蓄银行股份有限公司 | Data processing method and device of wind control model |
| CN109118353A (en) * | 2018-07-20 | 2019-01-01 | 中国邮政储蓄银行股份有限公司 | The data processing method and device of air control model |
| CN109272241A (en) * | 2018-09-29 | 2019-01-25 | 北京优全智汇信息技术有限公司 | One seed nucleus pays for method and apparatus |
| CN109559236A (en) * | 2018-10-27 | 2019-04-02 | 平安医疗健康管理股份有限公司 | The method and apparatus of drug reimbursement Information abnormity |
| CN109559236B (en) * | 2018-10-27 | 2023-08-08 | 深圳平安医疗健康科技服务有限公司 | Method and device for canceling information abnormality of medicines |
| CN109493242A (en) * | 2018-10-30 | 2019-03-19 | 平安医疗健康管理股份有限公司 | Unit joining insurance's recognition methods and Related product |
| CN109670974A (en) * | 2018-12-14 | 2019-04-23 | 中国平安人寿保险股份有限公司 | A kind of risk monitoring and control method and device, electric terminal |
| CN112767179B (en) * | 2021-01-11 | 2022-07-19 | 上海瀚之友信息技术服务有限公司 | Monitoring and early warning method and system for vehicle insurance value-added service |
| CN112767179A (en) * | 2021-01-11 | 2021-05-07 | 上海瀚之友信息技术服务有限公司 | Monitoring and early warning method and system for vehicle insurance value-added service |
| CN116307607A (en) * | 2023-03-24 | 2023-06-23 | 探保网络科技(广州)有限公司 | Insurance core system monitoring system and method |
| CN116308434A (en) * | 2023-05-12 | 2023-06-23 | 杭州大鱼网络科技有限公司 | Insurance fraud identification method and system |
| CN116308434B (en) * | 2023-05-12 | 2023-08-11 | 杭州大鱼网络科技有限公司 | Insurance fraud identification method and system |
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Application publication date: 20180202 |