CN108305175A - Settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping - Google Patents
Settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping Download PDFInfo
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- CN108305175A CN108305175A CN201711492585.3A CN201711492585A CN108305175A CN 108305175 A CN108305175 A CN 108305175A CN 201711492585 A CN201711492585 A CN 201711492585A CN 108305175 A CN108305175 A CN 108305175A
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- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06F—ELECTRIC DIGITAL DATA PROCESSING
- G06F16/00—Information retrieval; Database structures therefor; File system structures therefor
- G06F16/30—Information retrieval; Database structures therefor; File system structures therefor of unstructured textual data
- G06F16/36—Creation of semantic tools, e.g. ontology or thesauri
- G06F16/367—Ontology
Abstract
The settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping that the invention discloses a kind of, including input equipment, calculating and modelling apparatus, output equipment, input equipment includes medical knowledge data collection module, compensation case information collection module, system configuration module, it includes natural language processing module to calculate with modelling apparatus, data cleansing module, data import modul, medical knowledge collection of illustrative plates module, diagnosis and treatment and interest modeling module, diagnosis and treatment reasonability judgment module, output equipment includes the prompt of diagnosis and treatment reasonability and operation interface and the prompt of diagnosis and treatment reasonability and operation API, by the judgment result displays of system to Insurance Actuary, and receive the operation of Insurance Actuary, and it is integrated in the existing Claims Resolution system of insurance company as subsystem.The present invention deducts the project with Misdiagnosis or non-insurance coverage from compensation case automatically, improves Claims Resolution timeliness；Dependence of the Insurance Actuary to medical knowledge is reduced, cost is employed in reduction；Claims Resolution accuracy is improved, insurance company is reduced and compensates the amount of money.
Description
Technical field
The settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping that the present invention relates to a kind of.
Background technology
At present in work of settling a claim, following types of compensation case can be usually encountered：
(1) drug and diagnosis and treatment item used when insurant is medical is not consistent with the scope of insurance coverage that insurance contract is arranged：
For example once the medical middle a variety of diseases for the treatment of, which part disease belong to the Limitation on Liability of insurance company to insurant, but it is another
Part disease is not in the Limitation on Liability.The drug of the non-Limitation on Liability and diagnosis and treatment item insurance company need not compensate, but need to manage
Compensation person rejects this intermediate item；
(2) dosage for the drug or diagnosis and treatment item that insurant uses is more than zone of reasonableness, or similar in therapeutic effect
In the case of, insurant selects the higher therapeutic scheme of expense：Such situation is encountered, the Claims Resolution staff of insurance company is needed
The state of an illness for carefully analyzing patient is rejected excessive with unreasonable part.
The compensation case of processing the above-mentioned type needs have following requirement to the Insurance Actuary of insurance company：
(1) Insurance Actuary of insurance company has the medical ground knowledge of profession, while medical knowledge needs are newest with hospital
Therapeutic modality keep synchronize；
(2) it since patient's expense detail entry number of long-term inpatients is more, needs Insurance Actuary to spend a lot of time and audits one by one.
Customary risks company can employ the Insurance Actuary with medical speciality background, but since medicine is that classification is careful and professional
Property extremely strong subject, for example the Insurance Actuary with division of respiratory disease medical ground may understand the medication of Urology Surgery and diagnosis and treatment mode
It is not deep enough, while hospital can change to patient's therapeutic modality with region at any time, Insurance Actuary is difficult that comprehensive grasp is owned
Medical knowledge.
Due to the customer experience of Claims Resolution timeliness meeting extreme influence insurance company, the long Claims Review time can lead to client
Complaint and loss, or even will receive the punishment of supervision department, the compensation case that Insurance Actuary can not be more to expense detail number of entries
It does and audits one by one.
When encountering the above situation, insurance company would generally estimate rough compensation ratio according to Claims Resolution experience, and with
Insurer negotiates, and in order to make insurer be satisfied with, the compensation ratio that customary risks company provides is higher than normal compensation ratio.
Invention content
The present invention devises a kind of settlement of insurance claim air control based on intellectual medical knowledge mapping in view of the deficiencies of the prior art
Assisted verification system.
The present invention is in order to achieve the above object, using following scheme：A kind of settlement of insurance claim based on intellectual medical knowledge mapping
Air control assisted verification system, including input equipment, calculating and modelling apparatus, output equipment；
The input equipment includes medical knowledge data collection module, compensation case information collection module, system configuration module, institute
It states medical knowledge data collection module and extracts primitive medicine knowledge data from different data sets, the data set includes internet
Drug explanation after upper electronization, medical thesis, diagnosis and treatment knowledge base, include in settlement information in social security sector is medical and detailed
Information, the diagnosis and therapy recording in hospital HIS system, the compensation case information collection module read Insurance Actuary from the system of insurance company
Compensation case information to be treated, including the treatment that the demographic of insurer, insurer go to a doctor are detailed, the system configuration mould
Block is responsible for the global configuration of system, including the additions and deletions of data source, the collection period of data, the rational threshold value of diagnosis and treatment, interface are aobvious
Show style；
The calculating and modelling apparatus include natural language processing module, data cleansing module, data import modul, medicine
Knowledge mapping module, diagnosis and treatment and interest modeling module, diagnosis and treatment reasonability judgment module, the natural language processing module be responsible for by
Relationship is extracted between medical keywords and word in the unstructured data of electronization, is converted into the intelligible structuring number of computer
According to the data cleansing module is responsible for the rejectings such as the dirty data for being collected into system, corrupt data, the data import modul
It is responsible for cleaned data importing the medical knowledge collection of illustrative plates module, the medical knowledge collection of illustrative plates module is responsible in a manner of scheming
The medical knowledge being collected into is stored, the diagnosis and treatment and interest modeling module are responsible for extracting from the medical knowledge collection of illustrative plates module every
Corresponding point of age group of kind medical diagnosis on disease, gender and the diagnosis and treatment of region feature, the diagnosis and treatment reasonability judgment module are responsible for judgement
Whether the currently processed compensation case of Insurance Actuary is reasonable, and provides reasonable or unreasonable prompt and suggestion for operation；
The output equipment includes the prompt of diagnosis and treatment reasonability and operation interface and the prompt of diagnosis and treatment reasonability and operation API, institute
It states the prompt of diagnosis and treatment reasonability and is responsible for the judgment result displays by system to Insurance Actuary with operation interface, and receive the behaviour of Insurance Actuary
Make, the diagnosis and treatment reasonability prompt is integrated in the existing Claims Resolution system of insurance company with operation API using this system as subsystem, is
The system of insurance company provides the programmatic interface of this system.
Compared to the prior art the present invention, has the following advantages that and advantageous effect：
(1) it is deducted from insurance compensation case automatically and medical diagnosis on disease is not inconsistent or the project of non-insurance coverage, reduced artificial
The time of audit improves Claims Resolution timeliness；
(2) dependence of the business health insurance Insurance Actuary to medical knowledge is reduced, reduce Insurance Actuary employs cost；
(3) Claims Resolution accuracy is improved, insurance company is reduced and compensates the amount of money.
Description of the drawings
Fig. 1 is system structure of the invention figure；
Fig. 2 is flow chart of data processing figure of the present invention；
Fig. 3 is knowledge mapping graph model schematic diagram of the present invention；
Fig. 4 is that present system uses interface schematic diagram one；
Fig. 5 is that present system uses interface schematic diagram two；
Fig. 6 is that present system uses interface schematic diagram three；
Fig. 7 is that present system uses interface schematic diagram four；
Specific implementation mode
In conjunction with Fig. 1, a kind of settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping, including input are set
Standby, calculating and modelling apparatus, output equipment；
The input equipment includes medical knowledge data collection module, compensation case information collection module, system configuration module, institute
It states medical knowledge data collection module and extracts primitive medicine knowledge data from different data sets, the data set includes internet
Drug explanation after upper electronization, medical thesis, diagnosis and treatment knowledge base, include in settlement information in social security sector is medical and detailed
Information, the diagnosis and therapy recording in hospital HIS system, the compensation case information collection module read Insurance Actuary from the system of insurance company
Compensation case information to be treated includes the treatment gone to a doctor of demographic (gender, age, region etc.), insurer of insurer
Detail, the system configuration module are responsible for the global configuration of system, include additions and deletions, the collection period of data, the diagnosis and treatment of data source
Rational threshold value, interface display style etc.；
The calculating and modelling apparatus include natural language processing module, data cleansing module, data import modul, medicine
Knowledge mapping module, diagnosis and treatment and interest modeling module, diagnosis and treatment reasonability judgment module, the natural language processing module be responsible for by
Relationship is extracted between medical keywords and word in the unstructured data of electronization, is converted into the intelligible structuring number of computer
According to the data cleansing module is responsible for the rejectings such as the dirty data for being collected into system, corrupt data, the data import modul
It is responsible for cleaned data importing the medical knowledge collection of illustrative plates module, the medical knowledge collection of illustrative plates module is responsible in a manner of scheming
The medical knowledge being collected into is stored, the diagnosis and treatment and interest modeling module are responsible for extracting from the medical knowledge collection of illustrative plates module every
Corresponding point of age group of kind medical diagnosis on disease, gender and the diagnosis and treatment of region feature, the diagnosis and treatment reasonability judgment module are responsible for judgement
Whether the currently processed compensation case of Insurance Actuary is reasonable, and provides reasonable or unreasonable prompt and suggestion for operation；
The output equipment includes the prompt of diagnosis and treatment reasonability and operation interface and the prompt of diagnosis and treatment reasonability and operation API, institute
It states the prompt of diagnosis and treatment reasonability and is responsible for the judgment result displays by system to Insurance Actuary with operation interface, and receive the behaviour of Insurance Actuary
Make, the diagnosis and treatment reasonability prompt is integrated in the existing Claims Resolution system of insurance company with operation API using this system as subsystem, is
The system of insurance company provides the programmatic interface of this system.
As shown in Fig. 2, system data processing method and flow are as follows：First corresponding data has been collected into raw information
Under the premise of library, natural language processing module and data cleansing module are at first handled data, and unstructured data is turned
It is changed to structural data, while dirty data, wrong data being rejected from initial data.Common natural language processing kit
For the Stanford NLP Tools [1] of Stanford University's research and development, the natural language based on cloud of Google Cloud Platform
Speech processing API [2] etc.；Common data cleansing tool includes OpenRefine [3] etc..
After the completion of data cleansing, knowledge mapping is imported data to, several existing chart database can be used to store
Our structured medical diagnosis and treatment knowledge, common chart database include [5] Neo4j, OrientDB [6] etc., and specific system is real
It can be integrated and be chosen according to many factors such as data volume, database performance and prices during applying, different chart databases is equal
The api interface and tool for providing different language are imported for data.The graph model of chart database is as shown in figure 3, by patient, disease
The node as figure such as disease, doctor, section office, hospital, diagnosis and treatment item, drug, and established between node and node in chart database
Contact, such as certain patient A hospital H have M sections D doctor punish treat S diseases, medication K1, K2, K3, we by these
Entity is preserved as node, and corresponding drug dosage, the information such as hospital stays are stored in then as the relationship between node and node
In the side of graph model.Wherein patient and doctor's information for hospital can do anonymization processing, and patient only retains age-sex, and doctor only protects
The identification number for staying system to distribute, hospital Retention Level and regional information.
Modeling module can establish diagnosis and treatment reasonability model according to the information in chart database, and therefrom extract disease with it is corresponding
The characteristic set of diagnosis and treatment.For each disease X and each diagnosis and treatment item or drug Y in knowledge mapping, two can be all calculated
Relationship probability mass function P between person (Y | Age, Location, Sex, X), which suffers from X diseases, and age bracket is
Age, in the cities Location, gender is that the patient of Sex uses the probability of Y projects, wherein all variables are that discrete type is random
Variable.
The feature that judgment module can be extracted according to modeling module calculates medical diagnosis on disease and every detailed conjunction in specific compensation case
Rationality probability value, and it is divided into three classes according to all details for the threshold value of system setting：Rationally, unreasonable, uncertain.Finally,
Have output equipment by three classes detail include front end page for Insurance Actuary operate and use.
[1]Stanford NLP Tools https://nlp.stanford.edu/software/
[2]Cloud Natural Language API https://cloud.google.com/natural-
language/
[3]OpenRefine http://openrefine.org/
[4]Neo4j https://neo4j.com/
[5]OrientDB http://orientdb.com/orientdb/
In conjunction with Fig. 4 to Fig. 7, understands automatic prompt detail after using several diagrams at interface, system to be computed for system and examine
It is disconnected not to be inconsistent, it can check which and Misdiagnosis in specific detail, click are not inconsistent project after clicking to enter, Insurance Actuary can check not
Reason is accorded with, system can provide suggestion for operation, be selected by Insurance Actuary automatically.
The above is only a preferred embodiment of the present invention, it is noted that for the ordinary skill people of the art
For member, without departing from the technical principles of the invention, several improvements and modifications, these improvements and modifications can also be made
Also it should be regarded as protection scope of the present invention.
Claims (1)
1. a kind of settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping, it is characterised in that：Including input
Equipment, calculating and modelling apparatus, output equipment；
The input equipment includes medical knowledge data collection module, compensation case information collection module, system configuration module, the doctor
Data collection module of gaining knowledge extracts primitive medicine knowledge data from different data sets, and the data set includes that internet powers on
Drug explanation after sonization, medical thesis, diagnosis and treatment knowledge base, the medical and detailed letter for including in settlement information in social security sector
It ceases, the diagnosis and therapy recording in hospital HIS system, the compensation case information collection module reads Insurance Actuary from the system of insurance company and needs
Compensation case information to be processed, including the treatment that the demographic of insurer, insurer go to a doctor are detailed, the system configuration module
It is responsible for the global configuration of system, including the additions and deletions of data source, the collection period of data, the rational threshold value of diagnosis and treatment, interface display
Style；
The calculating and modelling apparatus include natural language processing module, data cleansing module, data import modul, medical knowledge
Collection of illustrative plates module, diagnosis and treatment and interest modeling module, diagnosis and treatment reasonability judgment module, the natural language processing module are responsible for electronics
Relationship is extracted between medical keywords and word in the unstructured data of change, is converted into the intelligible structural data of computer,
The data cleansing module is responsible for the rejectings such as the dirty data for being collected into system, corrupt data, and the data import modul is negative
Cleaned data are imported the medical knowledge collection of illustrative plates module by duty, and the medical knowledge collection of illustrative plates module is responsible for depositing in a manner of scheming
The medical knowledge being collected into is stored up, the diagnosis and treatment and interest modeling module are responsible for extracting each from the medical knowledge collection of illustrative plates module
Corresponding point of age group of medical diagnosis on disease, gender and the diagnosis and treatment of region feature, the diagnosis and treatment reasonability judgment module are responsible for judging reason
Whether the currently processed compensation case of compensation person is reasonable, and provides reasonable or unreasonable prompt and suggestion for operation；
The output equipment includes that the prompt of diagnosis and treatment reasonability prompts with operation interface and diagnosis and treatment reasonability and operates API, described to examine
It treats reasonability prompt and is responsible for the judgment result displays by system to Insurance Actuary with operation interface, and receive the operation of Insurance Actuary, institute
It states the prompt of diagnosis and treatment reasonability and is integrated in the existing Claims Resolution system of insurance company using this system as subsystem with operation API, for insurance
The system of company provides the programmatic interface of this system.
Priority Applications (1)
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| CN201711492585.3A CN108305175A (en) | 2017-12-30 | 2017-12-30 | Settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping |
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|---|---|---|---|
| CN201711492585.3A CN108305175A (en) | 2017-12-30 | 2017-12-30 | Settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping |
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| CN108305175A true CN108305175A (en) | 2018-07-20 |
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ID=62867934
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| CN201711492585.3A Pending CN108305175A (en) | 2017-12-30 | 2017-12-30 | Settlement of insurance claim air control assisted verification system based on intellectual medical knowledge mapping |
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Cited By (18)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN109191314A (en) * | 2018-08-14 | 2019-01-11 | 平安医疗健康管理股份有限公司 | Document method of charging out, device, computer equipment and storage medium |
| CN109345399A (en) * | 2018-10-23 | 2019-02-15 | 平安科技（深圳）有限公司 | Claims Resolution methods of risk assessment, device, computer equipment and storage medium |
| CN109615536A (en) * | 2018-12-13 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Settlement of insurance claim method, apparatus, equipment and readable storage medium storing program for executing based on OCR technique |
| 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 |
| CN109636632A (en) * | 2018-12-13 | 2019-04-16 | 平安医疗健康管理股份有限公司 | Settlement of insurance claim method, apparatus, equipment and storage medium based on machine learning |
| CN109636637A (en) * | 2018-12-13 | 2019-04-16 | 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 |
| CN109636305A (en) * | 2018-10-29 | 2019-04-16 | 平安医疗健康管理股份有限公司 | Compensate method of adjustment, device, equipment and the readable storage medium storing program for executing of the amount of money |
| CN109659013A (en) * | 2018-11-28 | 2019-04-19 | 平安科技（深圳）有限公司 | Illness point is examined and method for optimizing route, device, equipment and storage medium |
| CN110119991A (en) * | 2019-04-12 | 2019-08-13 | 深圳壹账通智能科技有限公司 | Checking method, device and storage medium are compensated in medical treatment based on machine learning |
| CN110245242A (en) * | 2019-06-20 | 2019-09-17 | 北京百度网讯科技有限公司 | Medical knowledge map construction method, apparatus and terminal |
| CN110322216A (en) * | 2019-05-30 | 2019-10-11 | 阿里巴巴集团控股有限公司 | The case checking method and device of knowledge based map |
| CN110689322A (en) * | 2019-09-27 | 2020-01-14 | 成都知识视觉科技有限公司 | Artificial intelligence auxiliary claims checking system suitable for insurance claims settlement process |
| CN110866836A (en) * | 2019-11-14 | 2020-03-06 | 支付宝(杭州)信息技术有限公司 | Computer-implemented medical insurance scheme auditing method and device |
| CN111445343A (en) * | 2020-03-23 | 2020-07-24 | 平安医疗健康管理股份有限公司 | Risk medical data identification method and device, computer equipment and storage medium |
| CN112463973A (en) * | 2019-09-06 | 2021-03-09 | 医渡云（北京）技术有限公司 | Construction method, device and medium of medical knowledge graph and electronic equipment |
| CN113360671A (en) * | 2021-06-16 | 2021-09-07 | 浙江工业大学 | Medical insurance medical document auditing method and system based on knowledge graph |
| CN116450727A (en) * | 2023-06-19 | 2023-07-18 | 中国人民解放军联勤保障部队第九八〇医院 | Medical data processing method, medical data processing device, terminal equipment and readable storage medium |
| CN113191908B (en) * | 2021-05-13 | 2024-03-12 | 蚂蚁胜信(上海)信息技术有限公司 | Method and device for processing claims settlement auditing |
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| CN109191314A (en) * | 2018-08-14 | 2019-01-11 | 平安医疗健康管理股份有限公司 | Document method of charging out, device, computer equipment and storage medium |
| CN109345399A (en) * | 2018-10-23 | 2019-02-15 | 平安科技（深圳）有限公司 | Claims Resolution methods of risk assessment, device, computer equipment and storage medium |
| CN109345399B (en) * | 2018-10-23 | 2024-03-26 | 平安科技（深圳）有限公司 | Method, device, computer equipment and storage medium for evaluating risk of claim settlement |
| CN109636305A (en) * | 2018-10-29 | 2019-04-16 | 平安医疗健康管理股份有限公司 | Compensate method of adjustment, device, equipment and the readable storage medium storing program for executing of the amount of money |
| CN109659013B (en) * | 2018-11-28 | 2023-07-07 | 平安科技（深圳）有限公司 | Disease diagnosis and path optimization method, device, equipment and storage medium |
| CN109659013A (en) * | 2018-11-28 | 2019-04-19 | 平安科技（深圳）有限公司 | Illness point is examined and method for optimizing route, device, equipment and storage medium |
| CN109615536A (en) * | 2018-12-13 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Settlement of insurance claim method, apparatus, equipment and readable storage medium storing program for executing based on OCR technique |
| 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 |
| CN109636632A (en) * | 2018-12-13 | 2019-04-16 | 平安医疗健康管理股份有限公司 | Settlement of insurance claim method, apparatus, equipment and storage medium based on machine learning |
| CN109636637A (en) * | 2018-12-13 | 2019-04-16 | 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 |
| CN110119991A (en) * | 2019-04-12 | 2019-08-13 | 深圳壹账通智能科技有限公司 | Checking method, device and storage medium are compensated in medical treatment based on machine learning |
| CN110322216A (en) * | 2019-05-30 | 2019-10-11 | 阿里巴巴集团控股有限公司 | The case checking method and device of knowledge based map |
| CN110245242A (en) * | 2019-06-20 | 2019-09-17 | 北京百度网讯科技有限公司 | Medical knowledge map construction method, apparatus and terminal |
| CN112463973A (en) * | 2019-09-06 | 2021-03-09 | 医渡云（北京）技术有限公司 | Construction method, device and medium of medical knowledge graph and electronic equipment |
| CN110689322A (en) * | 2019-09-27 | 2020-01-14 | 成都知识视觉科技有限公司 | Artificial intelligence auxiliary claims checking system suitable for insurance claims settlement process |
| CN110866836A (en) * | 2019-11-14 | 2020-03-06 | 支付宝(杭州)信息技术有限公司 | Computer-implemented medical insurance scheme auditing method and device |
| CN110866836B (en) * | 2019-11-14 | 2022-12-06 | 支付宝(杭州)信息技术有限公司 | Computer-implemented medical insurance scheme auditing method and device |
| CN111445343A (en) * | 2020-03-23 | 2020-07-24 | 平安医疗健康管理股份有限公司 | Risk medical data identification method and device, computer equipment and storage medium |
| CN113191908B (en) * | 2021-05-13 | 2024-03-12 | 蚂蚁胜信(上海)信息技术有限公司 | Method and device for processing claims settlement auditing |
| CN113360671A (en) * | 2021-06-16 | 2021-09-07 | 浙江工业大学 | Medical insurance medical document auditing method and system based on knowledge graph |
| CN113360671B (en) * | 2021-06-16 | 2022-04-19 | 浙江工业大学 | Medical insurance medical document auditing method and system based on knowledge graph |
| CN116450727A (en) * | 2023-06-19 | 2023-07-18 | 中国人民解放军联勤保障部队第九八〇医院 | Medical data processing method, medical data processing device, terminal equipment and readable storage medium |
| CN116450727B (en) * | 2023-06-19 | 2023-08-18 | 中国人民解放军联勤保障部队第九八〇医院 | Medical data processing method, medical data processing device, terminal equipment and readable storage medium |
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