CN106650208B - A kind of cost analysis system and method for medical insurance patient - Google Patents
A kind of cost analysis system and method for medical insurance patient Download PDFInfo
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- CN106650208B CN106650208B CN201610871094.9A CN201610871094A CN106650208B CN 106650208 B CN106650208 B CN 106650208B CN 201610871094 A CN201610871094 A CN 201610871094A CN 106650208 B CN106650208 B CN 106650208B
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Abstract
The invention discloses the cost analysis system and method for medical insurance patient a kind of, including computer system, initialization module, patient information recording module, medical expense generation module, medical expense judgment module and excess warning module, initialization module is for initializing all kinds of medical insurance diseases and department's medical insurance quota information expense；Patient information recording module is for the medical insurance of typing patient, disease and treatment information；The medical expense generation module Medical Consumption information daily for typing patient；Medical expense judgment module sees if fall out the expense of medical insurance quota information expense；The warning module is for issuing warning information when excess；The present invention includes that different drugs, different diagnosis and treatment item distinguish for the medical expenses of different disease group patients, judge whether it belongs in medical insurance coverage area and calculated, and prompting is made to doctor, reference is made for doctor's prescription, accuracy of the present invention is high, practicability is good, strong operability.
Description
Technical field
The present invention relates to medical technology management domain, the cost analysis system of especially a kind of medical insurance patient and side
Method.
Background technique
Medical insurance refers to that, by national legislation, taking according to mandatory social insurance principle basic medical insurance should be by employment
Unit and worker individual pay in full amount on time.Medical insurance collects medical guarantor to the people by threats in advance in a manner of contract
It is dangerous to take, establish Medical Benefits Fund；When insurant's illness and after going to medical institutions medical and medical expense occurs, protected by medical treatment
Certain economic compensation is given by dangerous mechanism.
The personal account fund that the risk-pooling fund and personal special project that the funds of basic medical insurance is used by overall social planning use
Composition.Individual's payment is all divided into personal account, and unit payment is divided into personal account by 30% or so, and rest part, which is established, to be planned as a whole
Fund.
The basic medical insurance terms of payment: firstly, insurant will see a doctor in basic medical insurance designated medical organization, purchase
Medicine can also purchase drug at fixed point retail pharmacies by prescription.Secondly, medical expense occurred has to comply with basic medical insurance.
Drug catalogue, diagnosis and treatment item, the range of medical services facility standard and payment standard, could be by the funds of basic medical insurance by rule
It is paid calmly.Third, to the medical expense for meeting the funds of basic medical insurance payment range, to distinguish is to belong to risk-pooling fund
Payment range still falls within personal account payment range.The medical expense for belonging to risk-pooling fund reimbursement range has been more than negative standard
Above is paid in proportion by risk-pooling fund, and highest payment is until medical insurance pays limit.
Medical insurance risk-pooling fund reimbursement mode: when medical insurance risk-pooling fund reimbursement mode is mainly that patient sees a doctor at present
It does not pay directly, is mutually settled accounts by hospital and Medical Insurance Organizations.Since Hospitals at Present medical cost management information system is endless
It is kind, lack the statistics to medical expense inside and outside medical insurance coverage, so that lacking when doctor's prescription in terms of medical expense
Reference, may cause the cost of medical insurance beyond payment limit, can not submit an expense account.
Summary of the invention
It is high that the purpose of the present invention is to provide a kind of accuracys, practicability it is good for calculating the cost of medical insurance and having
The cost analysis system and method for the medical insurance patient of warning function.
In order to solve the above-mentioned technical problem, the present invention is implemented as follows: a kind of cost analysis system of medical insurance patient
System, including computer system, initialization module, patient information recording module, medical expense generation module, medical expense judge mould
Block and excess warning module, the initialization module, patient information recording module, medical expense generation module, medical expense are sentenced
Disconnected module and excess warning module are connect with the computer system respectively by electric signal, and the initialization module, patient
Data input module, medical expense generation module, medical expense judgment module and excess warning module are connected by electric signal sequence
It connects, in which:
The initialization module initializes all kinds of medical insurance types, all kinds of for downloading medical insurance directory information
Disease and each department's medical insurance quota information expense；
The patient information recording module is for the medical insurance of typing patient, disease and treatment information；
The medical expense generation module Medical Consumption information daily for typing patient, then according to the medical treatment of patient
Insurance and treatment information expense, part expense and the classification of submitting an expense account entirely at one's own expense at one's own expense entirely by the progress of generated expense, then
The expense that partially expense is obtained multiplied by reimbursement ratio at one's own expense is summed with complete submit an expense account, obtains patient medical insurance coverage
Interior expense summation；According to partially expense and entirely submitting an expense account summation at one's own expense, general expenses is calculated in conjunction with the disease of patient, it is raw
At each section medical expense summation；
The medical expense judgment module is for determining each section payment for medical care summation of the generation with the medical insurance
Volume information expense is compared, and sees if fall out medical insurance quota information expense；
The warning module is used to issue early warning letter when each section expense summation exceeds medical insurance quota information expense
Breath；
The computer system is for handling, analyzing and saving the initialization module, patient information recording module, medical treatment
The data information of expense generation module, medical expense judgment module and excess warning module.
Preferably, the medical insurance quota information expense certain situation of each department are as follows: if patient is transferred from one department to another by n times
X department is gone to, then X department medical insurance quota information expense=original volume × 0.6 of X departmentn；If patient is not straight by transferring from one department to another
It taps into X department, then X department medical insurance quota information expense=original volume of X department.
Preferably, generating each section medical expense summation includes two kinds of situations: the first situation: when patient is common patient
When, it calculates Laboratory Fee and bed takes each section expense；If patient is Single diseases patient, each section expense of disease in each list is calculated
With.
Preferably, Single diseases patient includes orthopaedics Single diseases, PCI Single diseases and artificial lens Single diseases, wherein orthopaedics list
Each section expense of disease includes artificial replacement's expense and bed expense；Each section expense of the PCI Single diseases includes heart branch
Frame expense and bed take；Each section expense of the artificial lens Single diseases includes artificial lens expense and bed expense.
A kind of cost analysis method of medical insurance patient, the cost analysis system including a kind of medical insurance patient
System, this method the following steps are included:
Initialization: downloading medical insurance directory information, and initialize all kinds of medical insurance types, all kinds of diseases and each section
Room medical insurance quota information expense；
Patient information typing: medical insurance, disease and the treatment information of typing patient；
Medical expense generates: the daily Medical Consumption information of typing patient, then according to the medical insurance of patient and treatment
Generated expense is carried out full expense at one's own expense, part expense and full classification of submitting an expense account at one's own expense by information, then at one's own expense by part
The expense that expense is obtained multiplied by reimbursement ratio is summed with complete submit an expense account, and show that the expense in patient medical insurance coverage is total
With；According to partially expense and entirely submitting an expense account summation at one's own expense, general expenses is calculated in conjunction with the disease of patient, generates each section doctor
Treatment expense summation；
Medical expense judgement: by each section payment for medical care summation of the generation and the medical insurance quota information expense into
Row compares, and sees if fall out medical insurance quota information expense；
Early warning processing: warning information is issued when each section expense summation exceeds medical insurance quota information expense.
Preferably, the medical insurance quota information expense certain situation of each department are as follows: if patient is transferred from one department to another by n times
X department is gone to, then the original volume × 0.6n of X department medical insurance quota information expense=X department；If patient is not straight by transferring from one department to another
It taps into X department, then X department medical insurance quota information expense=original volume of X department.
Preferably, generating each section medical expense summation includes two kinds of situations: the first situation: when patient is common patient
When, it calculates Laboratory Fee and bed takes each section expense；If patient is Single diseases patient, each section expense of disease in each list is calculated
With.
Preferably, Single diseases patient includes orthopaedics Single diseases, PCI Single diseases and artificial lens Single diseases, wherein orthopaedics list
Each section expense of disease includes artificial replacement's expense and bed expense；Each section expense of the PCI Single diseases includes heart branch
Frame expense and bed take；Each section expense of the artificial lens Single diseases includes artificial lens expense and bed expense.
The beneficial effects of the present invention are: computer system of the present invention, initialization module, patient information recording module, medical treatment
Expense generation module, medical expense judgment module and the interaction of excess warning module divide for the expense of different disease group patient
Analysis method can include that different drugs, different diagnosis and treatment item are distinguished to different medical expense, judge whether it belongs to medical treatment
It in insurance coverage and is calculated, and prompting is made to doctor, make reference for doctor's prescription.Accuracy of the present invention
Height, practicability is good, strong operability.
Detailed description of the invention
Fig. 1 is a kind of functional block diagram of the cost analysis system of medical insurance patient of the present invention.
Fig. 2 is a kind of operation step map of the cost analysis method of medical insurance patient of the present invention.
Fig. 3 is a kind of Detailed operating procedures figure of the cost analysis method of medical insurance patient of the present invention.
Fig. 4 is a kind of Detailed operating procedures figure of the cost analysis method of medical insurance patient of the present invention.
Fig. 5 is a kind of Detailed operating procedures figure of the cost analysis method of medical insurance patient of the present invention.
Fig. 6-8 is the statement of expense figure that patient generates in the present embodiment.
Fig. 9 is the cost analysis method and step figure that patient generates in the present embodiment.
Figure 10-14 is that patient's hospitalization cost summarizes inventory figure in the present embodiment.
Specific embodiment
As shown in Figure 1, a kind of cost analysis system of medical insurance patient, including computer system, initialization module, disease
People's data input module, medical expense generation module, medical expense judgment module and excess warning module, the initialization mould
Block, patient information recording module, medical expense generation module, medical expense judgment module and excess warning module pass through electric signal
Connect respectively with the computer system, and the initialization module, patient information recording module, medical expense generation module,
Medical expense judgment module is connected with excess warning module by electric signal sequence, in which:
The initialization module initializes all kinds of medical insurance types, all kinds of for downloading medical insurance directory information
Disease and each department's medical insurance quota information expense, the medical insurance directory information are related medicals as defined in social security office
Insurance information, each department's medical insurance quota information expense are also the specific number depending on the medical insurance type of patient
Depending on how much volume will be according to the medical insurance type and payment amount of patient；
The patient information recording module is for the medical insurance of typing patient, disease and treatment information, these information are certainly
There is detailed record after patient admission in hospital system；
The medical expense generation module Medical Consumption information daily for typing patient, then according to the medical treatment of patient
Insurance and treatment information expense, part expense and the classification of submitting an expense account entirely at one's own expense at one's own expense entirely by the progress of generated expense, then
The expense that partially expense is obtained multiplied by reimbursement ratio at one's own expense is summed with complete submit an expense account, obtains patient medical insurance coverage
Interior expense summation T1, part AutoSum obtains all-in charge T2 to patient at one's own expense entirely；According to partially expense and full reimbursement at one's own expense
Expense summation T1 calculates general expenses in conjunction with the disease of patient, generates each section medical expense summation T3；
The medical expense judgment module is used for each section payment for medical care summation T3 of the generation and the medical insurance
Quota information expense is compared, and sees if fall out medical insurance quota information expense；
The warning module is used to issue early warning when each section expense summation T3 exceeds medical insurance quota information expense
Information；
The computer system is for handling, analyzing and saving the initialization module, patient information recording module, medical treatment
The data information of expense generation module, medical expense judgment module and excess warning module.
Specifically, the medical insurance quota information expense certain situation of each department are as follows: if patient is transferred from one department to another by n times
X department is gone to, then X department medical insurance quota information expense=original volume × 0.6 of X departmentn；If patient is not straight by transferring from one department to another
It taps into X department, then X department medical insurance quota information expense=original volume of X department.
And generating each section medical expense summation T3 includes two kinds of situations: the first situation: when patient is common patient,
Each section medical expense summation T3 is that Laboratory Fee and bed take each section expense summation；If patient is Single diseases patient, each portion
Dividing medical expense summation T3 is each section expense summation for calculating disease in each list.Here Single diseases patient includes orthopaedics list disease
Kind, PCI Single diseases and artificial lens Single diseases, wherein each section expense of orthopaedics Single diseases includes artificial replacement's expense and bed
Take；Each section expense of the PCI Single diseases includes cardiac stent expense and bed expense；Each portion of the artificial lens Single diseases
Point expense includes artificial lens expense and bed expense.
As shown in Figure 2-5, a kind of cost analysis method of medical insurance patient is protected including a kind of medical treatment as shown in Figure 1
The cost analysis system of dangerous patient, this method the following steps are included:
Initialization: downloading medical insurance directory information, and initialize all kinds of medical insurance types, all kinds of diseases and each section
Room medical insurance quota information expense；
Patient information typing: medical insurance, disease and the treatment information of typing patient；
Medical expense generates: the daily Medical Consumption information of typing patient, then according to the medical insurance of patient and treatment
Generated expense is carried out full expense at one's own expense, part expense and full classification of submitting an expense account at one's own expense by information, then at one's own expense by part
The expense that expense is obtained multiplied by reimbursement ratio is summed with complete submit an expense account, and show that the expense in patient medical insurance coverage is total
With；According to partially expense and entirely submitting an expense account summation at one's own expense, general expenses is calculated in conjunction with the disease of patient, generates each section doctor
Treatment expense summation；
Medical expense judgement: by each section payment for medical care summation of the generation and the medical insurance quota information expense into
Row compares, and sees if fall out the expense of medical insurance quota information expense；
Early warning processing: warning information is issued when each section expense summation exceeds medical insurance quota information expense.
A certain specific patient illustrates the present invention for hospitalize and reimbursement:
As shown in figs 6-8, certain patient Chen Baoer generates the statement of expense during hospital and is listed as follows:
1) 0.9% sodium chloride injection (Dongguan)
2) 0.9% sodium chloride injection (Zhejiang)
3) 3L surgical membrane (08 city of Jiangxi trick)
4) B grades of double rooms
5) II grades of nursing
6) cataract excusing from death emulsification enucleation+intraocular lens implantation
7) phenobarbital sodium injection
8) surface anesthesia
9) non-contact tonometer method or applanation tonometer method
10) compound sodium chloride injection (Shijiazhuang)
11) compound tropicamide eye drops (Changchun)
12) optical coherence tomography town and country (OCT)
13) intramuscular injection D
14) corneal topography inspection
15) corneal endothelium spectroscopy
16) keratometry
17) irrigation of lacrimal passage
18) slit lamp examination
19) funduscopy under slit-lamp
20) normal vision inspection
21) full diet
22) artificial lens (aspherical U.S.'s Baushe & Lomb 12) Shandong good fortune is auspicious
23) IOL Power measures
24) mydriasis
25) it is added using microscope
26) double room air-conditioning temperature-reducing takes
27) small dressing
28) adrenalin hydrochloride injection
29) eye-ground photography
30) disposable wearing bayonet (U.S. 08) Guangzhou is won happy
31) viscoelastic agent (its victory 06 of ophthalmically acceptable Shanghai)
32) hospitalized to have a thorough examination to take
33) syringe (high 06 province of prestige recruits)
34) Injection-use reptilase
As shown in figure 9, it is complete at one's own expense, a that medical expense generated can be divided into individual according to medical expense computational algorithm
Part is submitted an expense account in people part at one's own expense and entirely, and the expense in patient medical insurance coverage is calculated.Patient is divided into again later general
Common fault people or Single diseases patient, the patient Chen Baoer in the old precious present case of patient in present case belong to artificial lens Single diseases disease
Its artificial crystal material is taken and individually calculates summation by people.
As shown in figures 10-14, from design schedule as it can be seen that patient medical insurance payment amount be 4800 yuan, produced doctor
Treating medical expense in insurance coverage is 5952.36 yuan, 1152.36 yuan of excess.In addition, the personal full amount of money at one's own expense is 1799 yuan, it is a
The amount of money is 0 yuan at one's own expense for people part, and it is 1488.09 yuan that basic medical insurance, which pays the amount of money for oneself,.And artificial lens Single diseases pay amount
It is 1800 yuan, wherein paying the amount of money for oneself is 360 yuan, planning as a whole charged amount is 1440 yuan, and produced practical artificial lens Single diseases
Expense is 3584 yuan, and overages are included in the full amount of money at one's own expense.
Computer system of the present invention, initialization module, patient information recording module, medical expense generation module, payment for medical care
It can be to different doctors for the cost analysis method of different disease group patient with the interaction of judgment module and excess warning module
Treatment expense includes that different drugs, different diagnosis and treatment item distinguish, and judges whether it belongs in medical insurance coverage area and goes forward side by side
Row calculates, and makes prompting to doctor, makes reference for doctor's prescription.Accuracy of the present invention is high, and practicability is good, can operate
Property is strong.
According to the disclosure and teachings of the above specification, those skilled in the art in the invention can also be to above-mentioned embodiment party
Formula is changed and is modified.Therefore, the invention is not limited to the specific embodiments disclosed and described above, to of the invention
Some modifications and changes should also be as falling into the scope of the claims of the present invention.In addition, although being used in this specification
Some specific terms, these terms are merely for convenience of description, does not limit the present invention in any way.
Claims (6)
1. a kind of cost analysis system of medical insurance patient, which is characterized in that including computer system, initialization module, disease
People's data input module, medical expense generation module, medical expense judgment module and excess warning module, the initialization mould
Block, patient information recording module, medical expense generation module, medical expense judgment module and excess warning module pass through electric signal
Connect respectively with the computer system, and the initialization module, patient information recording module, medical expense generation module,
Medical expense judgment module is connected with excess warning module by electric signal sequence, in which:
The initialization module initializes all kinds of medical insurance types, all kinds of diseases for downloading medical insurance directory information
With each department's medical insurance quota information；
The patient information recording module is for the medical insurance of typing patient, disease and treatment information；
The medical expense generation module Medical Consumption information daily for typing patient, then according to the medical insurance of patient
Generated expense is carried out full expense at one's own expense, part with treatment information expense and entirely to submit an expense account classification at one's own expense, then by part
The expense that expense is obtained multiplied by reimbursement ratio at one's own expense is summed with complete submit an expense account, and obtains the expense in patient medical insurance coverage
Use summation；According to partially expense and entirely submitting an expense account summation at one's own expense, general expenses is calculated in conjunction with the disease of patient, generates each portion
Divide medical expense summation；
The medical expense judgment module is used to believe each section payment for medical care summation of the generation and medical insurance quota
Breath expense is compared, and judges whether each section payment for medical care summation exceeds medical insurance quota information expense；
The warning module is used to issue warning information when each section expense summation exceeds medical insurance quota information expense；
The computer system is for handling, analyzing and saving the initialization module, patient information recording module, medical expense
The data information of generation module, medical expense judgment module and excess warning module；
If patient is transferred from one department to another by n times goes to X department, X department medical insurance quota information expense=original volume × 0.6 of X departmentn；
If patient is not directly entered X department by transferring from one department to another, the X department medical insurance quota information expense=original volume of X department.
2. a kind of cost analysis system of medical insurance patient as described in claim 1, which is characterized in that generate each section doctor
Treatment expense summation includes two kinds of situations: the first situation: when patient is common patient, calculating Laboratory Fee and bed takes each section
Expense；If patient is Single diseases patient, each section expense of disease in each list is calculated.
3. a kind of cost analysis system of medical insurance patient as claimed in claim 2, which is characterized in that Single diseases patient packet
Orthopaedics Single diseases, PCI Single diseases and artificial lens Single diseases are included, wherein each section expense of orthopaedics Single diseases includes artificial replacement
Expense and bed take；Each section expense of the PCI Single diseases includes cardiac stent expense and bed expense；The artificial lens list
Each section expense of disease includes artificial lens expense and bed expense.
4. a kind of cost analysis method of medical insurance patient, including a kind of any Medical Insurance Disease of claim 1-3
The cost analysis system of people, which is characterized in that this method the following steps are included:
Initialization: downloading medical insurance directory information, and initialize all kinds of medical insurance types, all kinds of diseases and each department doctor
Treat insurance quota information expense；
Patient information typing: medical insurance, disease and the treatment information of typing patient；
Medical expense generates: the daily Medical Consumption information of typing patient, then according to the medical insurance of patient and treatment information
Generated expense is carried out full expense at one's own expense, part expense and entirely to submit an expense account classification at one's own expense, it then will partially expense at one's own expense
The expense obtained multiplied by reimbursement ratio is summed with complete submit an expense account, and obtains the expense summation in patient medical insurance coverage；
According to partially expense and entirely submitting an expense account summation at one's own expense, general expenses is calculated in conjunction with the disease of patient, generates each section medical treatment
Expense summation；
Medical expense judgement: each section payment for medical care summation of the generation and the medical insurance quota information expense are compared
Compared with seeing if fall out medical insurance quota information expense；
Early warning processing: warning information is issued when each section expense summation exceeds medical insurance quota information expense；
If patient is transferred from one department to another by n times goes to X department, X department medical insurance quota information expense=original volume × 0.6 of X departmentn；
If patient is not directly entered X department by transferring from one department to another, the X department medical insurance quota information expense=original volume of X department.
5. a kind of cost analysis method of medical insurance patient as claimed in claim 4, which is characterized in that generate each section doctor
Treatment expense summation includes two kinds of situations: the first situation: when patient is common patient, calculating Laboratory Fee and bed takes each section
Expense；If patient is Single diseases patient, each section expense of disease in each list is calculated.
6. a kind of cost analysis method of medical insurance patient as claimed in claim 5, which is characterized in that Single diseases patient packet
Orthopaedics Single diseases, PCI Single diseases and artificial lens Single diseases are included, wherein each section expense of orthopaedics Single diseases includes artificial replacement
Expense and bed take；Each section expense of the PCI Single diseases includes cardiac stent expense and bed expense；The artificial lens list
Each section expense of disease includes artificial lens expense and bed expense.
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| CN201610871094.9A CN106650208B (en) | 2016-09-30 | 2016-09-30 | A kind of cost analysis system and method for medical insurance patient |
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| CN201610871094.9A CN106650208B (en) | 2016-09-30 | 2016-09-30 | A kind of cost analysis system and method for medical insurance patient |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN109545308A (en) * | 2018-10-22 | 2019-03-29 | 平安医疗健康管理股份有限公司 | The exceeded method for early warning of prescriptions of traditional Chinese medicine drug expenditure and device based on data processing |
| CN109559791A (en) * | 2018-10-22 | 2019-04-02 | 平安医疗健康管理股份有限公司 | The exceeded method for early warning of prescriptions of traditional Chinese medicine drug expenditure and device based on data processing |
| CN109767338A (en) * | 2018-11-30 | 2019-05-17 | 平安科技（深圳）有限公司 | Processing method, device, equipment and the readable storage medium storing program for executing of enterogastritis reimbursement process |
| CN109615544A (en) * | 2018-12-13 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Submit an expense account processing method, device, terminal and computer readable storage medium |
| CN109472519A (en) * | 2018-12-13 | 2019-03-15 | 湖南德雅曼达科技有限公司 | A method of building hospital infection control measure Cost benefit assessment model |
| CN109636649A (en) * | 2018-12-13 | 2019-04-16 | 平安医疗健康管理股份有限公司 | Monitoring method, monitoring service end and the storage medium of medical expense exception |
| CN109741193A (en) * | 2018-12-14 | 2019-05-10 | 新博卓畅技术（北京）有限公司 | A kind of medical insurance Single diseases control charge system and method |
| CN109741195A (en) * | 2018-12-27 | 2019-05-10 | 泰康保险集团股份有限公司 | Medical insurance data processing method, system, equipment and storage medium based on disease |
| CN110033311A (en) * | 2019-03-13 | 2019-07-19 | 武汉金豆医疗数据科技有限公司 | A kind of disease score value payment methods and system |
| CN113658653A (en) * | 2021-08-20 | 2021-11-16 | 挂号网（杭州）科技有限公司 | Diagnosis and treatment information processing method, device and equipment |
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