CN102945235A - Data mining system facing medical insurance violation and fraud behaviors - Google Patents
Data mining system facing medical insurance violation and fraud behaviors Download PDFInfo
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- CN102945235A CN102945235A CN2011102341488A CN201110234148A CN102945235A CN 102945235 A CN102945235 A CN 102945235A CN 2011102341488 A CN2011102341488 A CN 2011102341488A CN 201110234148 A CN201110234148 A CN 201110234148A CN 102945235 A CN102945235 A CN 102945235A
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Abstract
The invention provides a data mining system facing violation and fraud behaviors in the medical insurance, which belongs to the field of data mining and particularly relates to the data mining system facing the medical insurance violation and fraud behaviors. The system comprises a control layer manager, an execution layer manager and a data layer manager; the control layer manager is used for controlling the execution layer manager and comprises a data analysis module, a mining and guiding module and a mode screening module; the execution layer manager is used for directly controlling the processing operation of data stream and comprises a data preprocessing module, a mining kernel module and a rule generating module; and the data layer manager is used for storing all data generated in the whole process from the mining of original data to the stop of the mining process. The system can extract stored information as much as possible from mass of medical data comprising redundant information, extracts characteristic models beneficial for carrying out judgment and comparison and can identify the violation and fraud behaviors in the medical insurance according to the models.
Description
Technical field
The invention belongs to Data Mining, be specifically related to Proportion of Medical Insurance Charges in violation of rules and regulations and the data digging system of fraud.
Background technology
Medical insurance is as the part of entire society's safeguards system, brought into play Main Function aspect All labourer healthy ensureing, yet meanwhile, again and again " medical insurance swindle and the in violation of rules and regulations " phenomenon that is reported in media is but injected and is quietly accompanied with it as the moth, medical insurance its how with endless in violation of rules and regulations, the medical insurance reform difficulty outside medical insurance, as; Play tricks that memo ticket, cape horn fever are gone through, vacation is write out a prescription and the outpatient registered and be in hospital etc., gain insurance fund by cheating, swindle and unlawful practice are more and more frequent, and swindle and violation means are more and more brilliant.
Summary of the invention
The present invention refines by processing and excavation to the magnanimity transaction data, detects in real time the violation and the fraud that occur in the Health insurance system.
The Proportion of Medical Insurance Charges violation of the present invention's invention and the data digging system of fraud comprise:
Key-course manager, execution level manager and data Layer manager;
Described key-course manager is used for control execution level manager, comprises data analysis module, excavates to guide module and pattern screening module;
Described execution level manager is used for the directly processing operation of control data stream, comprises data preprocessing module, excavates kernel module and regular generation module;
Described data Layer manager is used for storage and ends all data that whole process produces from the raw data to the mining process.
Data preprocessing module in the above-mentioned execution level manager comprises: data acquisition module, data reduction module, data selection module, data purification module and data conversion module;
Data mining kernel module in the above-mentioned execution level manager comprises: sorting technique module, clustering method module, association analysis module and sequence pattern module;
Regular generation module in the above-mentioned execution level manager comprises: characteristic extracting module, filter module, model tormulation module and visualization model.
Above-mentioned data Layer manager comprises raw data module, data warehouse module, behavior library module, case library module, diagnosis and treatment path module, model bank module and rule base module.
The data digging system of Proportion of Medical Insurance Charges violation provided by the invention and fraud can extract the information of containing as much as possible from the medical data that comprises in a large number redundant information, extract and be conducive to the characteristic model judging and compare, according to these models, can identify swindle and unlawful practice in the medical insurance.
Description of drawings
Fig. 1 is the module diagram of the data digging system of Proportion of Medical Insurance Charges violation of the present invention and fraud.
Embodiment
The present invention invention towards medical treatment in violation of rules and regulations and the module diagram of the data digging system of fraud as shown in Figure 1, this system comprises key-course manager, execution level manager and data Layer manager;
Described key-course manager is used for control execution level manager, comprises data analysis module, excavates to guide module and pattern screening module;
Described execution level manager is used for the directly processing operation of control data stream, comprises data preprocessing module, excavates kernel module and regular generation module;
Wherein data preprocessing module comprises: data acquisition module, data reduction module, data selection module, data purification module and data conversion module;
Wherein the data mining kernel module comprises: sorting technique module, clustering method module, association analysis module and sequence pattern module;
Wherein regular generation module comprises: characteristic extracting module, filter module, model tormulation module and visualization model.
Described data Layer manager is used for storage and ends all data that whole process produces from the raw data to the mining process.
Wherein comprise raw data module, data warehouse module, behavior library module, case library module, diagnosis and treatment path module, model bank module and rule base module according to shelf manager.
Claims (3)
1. the Proportion of Medical Insurance Charges violation of the present invention's invention and the data digging system of fraud is characterized in that, comprising:
Key-course manager, execution level manager and data Layer manager;
Described key-course manager is used for control execution level manager, comprises data analysis module, excavates to guide module and pattern screening module;
Described execution level manager is used for the directly processing operation of control data stream, comprises data preprocessing module, excavates kernel module and regular generation module;
Described data Layer manager is used for storage and ends all data that whole process produces from the raw data to the mining process.
2. the data digging system of Proportion of Medical Insurance Charges violation as claimed in claim 1 and fraud is characterized in that,
Described data preprocessing module comprises: data acquisition module, data reduction module, data selection module, data purification module and data conversion module;
Described data mining kernel module comprises: sorting technique module, clustering method module, association analysis module and sequence pattern module;
Described regular generation module comprises: characteristic extracting module, filter module, model tormulation module and visualization model.
3. Proportion of Medical Insurance Charges as claimed in claim 2 in violation of rules and regulations and the data digging system of fraud, it is characterized in that, described data Layer manager comprises raw data module, data warehouse module, behavior library module, case library module, diagnosis and treatment path module, model bank module and rule base module.
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| Application Number | Priority Date | Filing Date | Title |
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| CN2011102341488A CN102945235A (en) | 2011-08-16 | 2011-08-16 | Data mining system facing medical insurance violation and fraud behaviors |
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| CN2011102341488A CN102945235A (en) | 2011-08-16 | 2011-08-16 | Data mining system facing medical insurance violation and fraud behaviors |
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| CN102945235A true CN102945235A (en) | 2013-02-27 |
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| CN2011102341488A Pending CN102945235A (en) | 2011-08-16 | 2011-08-16 | Data mining system facing medical insurance violation and fraud behaviors |
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Cited By (12)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN104408547A (en) * | 2014-10-30 | 2015-03-11 | 浙江网新恒天软件有限公司 | Data-mining-based detection method for medical insurance fraud behavior |
| CN105159948A (en) * | 2015-08-12 | 2015-12-16 | 成都数联易康科技有限公司 | Medical insurance fraud detection method based on multiple features |
| CN105608076A (en) * | 2014-10-09 | 2016-05-25 | 华院数据技术(上海)有限公司 | System and method for detecting abnormal diagnostic item in medical claims |
| CN106228000A (en) * | 2016-07-18 | 2016-12-14 | 北京千安哲信息技术有限公司 | Over-treatment detecting system and method |
| CN106959954A (en) * | 2016-01-11 | 2017-07-18 | 华院数据技术(上海)有限公司 | A kind of System and method for for being used to detect that entry is submitted an expense account in abnormality medical insurance |
| CN107133437A (en) * | 2017-03-03 | 2017-09-05 | 平安医疗健康管理股份有限公司 | The method and device that monitoring medicine is used |
| CN107145587A (en) * | 2017-05-11 | 2017-09-08 | 成都四方伟业软件股份有限公司 | A kind of anti-fake system of medical insurance excavated based on big data |
| CN107657536A (en) * | 2017-02-20 | 2018-02-02 | 平安科技（深圳）有限公司 | The recognition methods of social security fraud and device |
| CN109598628A (en) * | 2018-11-30 | 2019-04-09 | 平安医疗健康管理股份有限公司 | Recognition methods, device, equipment and the readable storage medium storing program for executing of medical insurance fraud |
| CN109791679A (en) * | 2016-09-26 | 2019-05-21 | 哈曼国际工业有限公司 | The system and method for prediction for automobile guarantee fraud |
| CN110851486A (en) * | 2018-07-26 | 2020-02-28 | 珠海格力电器股份有限公司 | Data storage method and device |
| CN113627525A (en) * | 2021-08-10 | 2021-11-09 | 工银科技有限公司 | Training method of feature extraction model, and medical insurance risk identification method and device |
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Cited By (16)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN105608076A (en) * | 2014-10-09 | 2016-05-25 | 华院数据技术(上海)有限公司 | System and method for detecting abnormal diagnostic item in medical claims |
| CN104408547A (en) * | 2014-10-30 | 2015-03-11 | 浙江网新恒天软件有限公司 | Data-mining-based detection method for medical insurance fraud behavior |
| CN104408547B (en) * | 2014-10-30 | 2017-09-15 | 浙江网新恒天软件有限公司 | A kind of detection method of the medical insurance fraud based on data mining |
| CN105159948A (en) * | 2015-08-12 | 2015-12-16 | 成都数联易康科技有限公司 | Medical insurance fraud detection method based on multiple features |
| CN105159948B (en) * | 2015-08-12 | 2019-04-02 | 成都数联易康科技有限公司 | A kind of Medicare fraud detection method based on multiple features |
| CN106959954A (en) * | 2016-01-11 | 2017-07-18 | 华院数据技术(上海)有限公司 | A kind of System and method for for being used to detect that entry is submitted an expense account in abnormality medical insurance |
| CN106228000A (en) * | 2016-07-18 | 2016-12-14 | 北京千安哲信息技术有限公司 | Over-treatment detecting system and method |
| CN109791679A (en) * | 2016-09-26 | 2019-05-21 | 哈曼国际工业有限公司 | The system and method for prediction for automobile guarantee fraud |
| CN107657536A (en) * | 2017-02-20 | 2018-02-02 | 平安科技（深圳）有限公司 | The recognition methods of social security fraud and device |
| CN107657536B (en) * | 2017-02-20 | 2018-07-31 | 平安科技（深圳）有限公司 | The recognition methods of social security fraud and device |
| CN107133437B (en) * | 2017-03-03 | 2018-09-14 | 平安医疗健康管理股份有限公司 | The method and device that monitoring drug uses |
| CN107133437A (en) * | 2017-03-03 | 2017-09-05 | 平安医疗健康管理股份有限公司 | The method and device that monitoring medicine is used |
| CN107145587A (en) * | 2017-05-11 | 2017-09-08 | 成都四方伟业软件股份有限公司 | A kind of anti-fake system of medical insurance excavated based on big data |
| CN110851486A (en) * | 2018-07-26 | 2020-02-28 | 珠海格力电器股份有限公司 | Data storage method and device |
| CN109598628A (en) * | 2018-11-30 | 2019-04-09 | 平安医疗健康管理股份有限公司 | Recognition methods, device, equipment and the readable storage medium storing program for executing of medical insurance fraud |
| CN113627525A (en) * | 2021-08-10 | 2021-11-09 | 工银科技有限公司 | Training method of feature extraction model, and medical insurance risk identification method and device |
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