CN109523265A - Whole process automatic auditing method and system are settled accounts in medical insurance - Google Patents
Whole process automatic auditing method and system are settled accounts in medical insurance Download PDFInfo
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- CN109523265A CN109523265A CN201811204297.8A CN201811204297A CN109523265A CN 109523265 A CN109523265 A CN 109523265A CN 201811204297 A CN201811204297 A CN 201811204297A CN 109523265 A CN109523265 A CN 109523265A
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Abstract
The application provides a kind of medical insurance clearing whole process automatic auditing method and system, checking method includes: building audit engine unit, advance auditing unit, audits unit and post audit unit in thing, and audit engine unit includes standardized module, regular auditing module and counter cheats module；Unit and post audit unit are audited in advance auditing unit, thing carries out information exchange with audit engine unit, it audits engine unit and regular audit is carried out to original medical data, regular audit is carried out to the data that advance auditing passes through, regular audit and anti-fraud calculating are carried out to the data passed through are audited in thing, the medical insurance initial data passed through for post audit and clearing forms data obtain medical insurance Closing Check result.The application can integrally cover medical services overall process, be truly realized prompting, mid-event control, post audit in advance by auditing unit and post audit unit in building audit engine unit, advance auditing unit, thing.
Description
Technical field
The application belongs to HMO Administrator technical field, and in particular to a kind of medical insurance clearing whole process automatic auditing method
And system.
Background technique
With the continuous growth of social economy, the medical service level in China is also obviously improved, and medical insurance expenditure is in
The trend risen year by year.Medical insurance work is also faced with huge medical insurance Closing Check work while achieving many achievements
Pressure.In order to cope with huge medical insurance Closing Check work, the medical act of hospital is standardized, is fundamentally guaranteed insured
The legitimate rights and interests of people, and realize the balance between revenue and expenditure and safety of medical insurance fund, it is necessary to existing medical insurance examination into
Row improves and innovation.
It in the prior art, is artificial review to audit, verification of medical insurance reimbursement document etc., i.e. auditor holds report
Pin document is checked one by one, and review efficiency and Quality of Auditing are low, it is easy to omit the reimbursement document data of violation, and then occur big
The suspicious actions such as fraud, abuse, the waste of amount, cause Medical Benefits Fund to incur loss.In addition, to medical insurance reimbursement document
Audit be concentrated mainly on clearing after audit, entire review process can not be monitored, not can avoid thus in violation of rules and regulations
The generation of behavior is only to punish to the unlawful practice occurred after the completion of clearing, lacks the control in prompting and thing in advance.
Due to being had differences between the careful medical insurance data standard of existing hospital data standard and core, hospital data into
Enter the matching that data code between artificial carry out standard is needed when medical insurance audit, this not only adds artificial implementation cost, efficiency
Lowly, and for some there is word that can not audit without the not high data of the qualities of data such as code.In the prior art mainly according to
According to the big catalogue of medical insurance three, the extraction for carrying out rule is summarized, in conjunction with information personal in clearing forms data, designated medical organization
Information carries out the data that collision comparison filters out violation with rule one by one.This audit mode is mainly audited according to rule,
Violation, fraud except rule are then had no way out, and the anti-fraud that shortage carries out intersecting in various dimensions big data identification is patrolled
Volume, so that the result that simple regular audit mode detected is limited, it cannot preferably protect the risk that medical insurance fund uses.
Summary of the invention
To be overcome the problems, such as present in the relevant technologies at least to a certain extent, this application provides a kind of medical insurance clearing are complete
Process automatic auditing method and system.
According to the embodiment of the present application in a first aspect, this application provides a kind of medical insurances to settle accounts the whole process side of audit automatically
Method comprising following steps:
Building audit engine unit, audits unit and post audit unit, the advance auditing in thing at advance auditing unit
Unit and post audit unit are audited in unit, thing carries out information exchange with audit engine unit；The audit engine unit
Including standardized module, regular auditing module and counter cheat module；The standardized module is used to carry out original medical data
Standardization, the rule auditing module is used to carry out regular audit to the data after standardization using rule when operation, described anti-
Fraud module is used to determine that the medical state of patient to be normal, suspicious or fraud；
The advance auditing unit obtains the medical initial data of patient, and the medical initial data that will acquire be sent to it is careful
Core engine unit, audit engine unit is using standardized module by original data processing at standardized data, audit engine list
Rule when standardized data and operation is carried out the matching primitives of word and word using regular auditing module by member, obtains matching knot
Fruit；The rule auditing module is using authenticity rule and compliance rule；The audit engine unit does not lead to advance auditing
The data feedback crossed gives advance auditing unit, and does prompting processing；The data that audit engine unit passes through advance auditing are sent
To auditing unit in thing；
Unit being audited in the thing, the data that the advance auditing received passes through being sent to audit engine unit, audit is drawn
It holds up unit and is processed into standardized data using the data that standardized module passes through advance auditing, audit engine unit utilizes rule
Then rule when standardized data and operation is carried out the matching primitives of word and word by auditing module, obtains matching result；The rule
Then auditing module is using authenticity rule, compliance rule and reasonability rule；Knot is generated for auditing the data passed through in thing
Forms data is calculated, engine unit is audited by the data passed through are audited in the clearing forms data and thing of generation and is all sent to post audit list
Member；
Post audit unit will audit the data passed through and be sent to audit engine unit in the thing received, audit engine list
Member will audit the data passed through using standardized module and be processed into standardized data in thing, audit engine unit is examined using rule
Rule when standardized data and operation is carried out the matching primitives of word and word by core module, obtains matching result；The rule is examined
Core module is using authenticity rule, compliance rule, reasonability rule and legitimacy rule；The medical insurance passed through for post audit
Initial data and clearing forms data obtain medical insurance Closing Check result.
Further, the building process of the standardized module are as follows:
For crowd, gender, Hospital Grade, hospital category, department, doctor's rank, coverage, disease, drug, rule
Lattice, packaging packaging material, operation, check that Various types of data establishes this body surface respectively at dosage form, and the data in described body surface include ontology word
It is numbered with this pronouns, general term for nouns, numerals and measure words；Described pronouns, general term for nouns, numerals and measure words is the unique and unduplicated word being of practical significance；
For different classes of ontology data, the corresponding synonym table of ontology data is established；The synonym and this pronouns, general term for nouns, numerals and measure words
Between be many-to-one relationship；
All kinds of terms in initial data are extracted, and the term of extraction is subjected to word with synonym corresponding in synonym table
With the comparison of word, corresponding pronouns, general term for nouns, numerals and measure words of such term or this pronouns, general term for nouns, numerals and measure words number are obtained after comparison is consistent；
Its run time format is generated for pending data；The run time format of the pending data are as follows: attribute |
Attribute value | affiliated attribute | #；The attribute list shows data type, and the attribute value table shows the numerical value of data type, described affiliated
Attribute indicates attribute belonging to the attribute.
Further, the building process of regular auditing module are as follows:
Structuring Closing Check rule is extracted from three mesh of medical insurance, National Formulary management and package insert file, and
Structuring Closing Check rule is classified according to authenticity rule, legitimacy rule, compliance rule and reasonability rule；
By sorted structuring Closing Check rule process at rule when operation；The structuring Closing Check rule
The format of rule when operation are as follows: subject name | rule numbers | attribute | calculate symbol | the corresponding value of attribute | logical symbol | terminate
Symbol |；The subject name indicates that the core subject of the rule, the rule numbers indicate unique volume of every independent rules
Number, the attribute indicates the data type with rule match, it is described calculate symbol indicate rule calculate in be greater than, be less than, etc.
In the corresponding specific value of each attribute of the corresponding value expression of attribute, the logical symbol is AND, OR, NOT or NULL；
The terminating symbol indicates the terminating symbol # of rule when each operation；
Regular subject name when to operation in rule carries out Chinese inverted index, formation rule index database；
The rule when data and operation of run time format is compared and logical operation, matching result is obtained.
Further, the authenticity rule include restriction crowd diagnosis and treatment, limit crowd's medication, limit gender diagnosis and treatment,
Limit gender medication；The legitimacy rule includes limiting hospital grade, limiting hospital category medication, limit doctor's rank use
Medicine limits clinician's types, limits hospital category, limits doctor's rank；The reasonability rule includes unreasonable administration route, spy
Different crowd's medication, pharmaceutical incompatibility, unreasonable drug combination, the medication of over adaptation disease, overdose, super course for the treatment of medication, overclocking
Secondary medication；The compliance rule limit idicatio medication, limit course for the treatment of medication, limit department's medication, limit insured mankind's type,
Limit the medication of medical insurance fund classification, limit outpatient service medication, limit be hospitalized medication, limit diagnosis and treatment medication, limit to other drugs without
Medication, restriction drug combination, the restriction of effect are unable to drug combination, limit compound use.
Further, the building process of the anti-fraud module are as follows:
Data clusters are carried out to the data after standardization according to consultation time and patient's name；
The medical state of patient is determined according to the consultation time of patient in data after cluster and place；
Patient one day medical services number is counted, and the medical services number that statistics is obtained and preset doctor
It treats service times threshold value to be compared, the medical state of patient is determined according to comparison result；
Mutual school is carried out to diagnosis, drug and prescription in the data after standardization, doctor's advice, inspection, inspection, surgical data
It tests, and determines the medical state of patient according to check results.
Further, the step determines that patient's is medical according to the consultation time of patient in data after cluster and place
The detailed process of state are as follows:
The latitude and longitude coordinates of the medical hospital of patient twice in succession are picked up using coordinate pick tool；
Calculate the distance between medical hospital twice in succession；
Consultation time interval is calculated by the time medical twice；
It is gone to a doctor speed using the distance between medical hospital twice in succession and consultation time interval calculation；
Medical speed is compared with preset medical velocity interval, and determines the medical shape of patient according to comparison result
State is normal, suspicious or fraud.
Further, the step counts patient one day medical services number, and the doctor that statistics is obtained
It treats service times to be compared with preset medical services frequency threshold value, the mistake of the medical state of patient is determined according to comparison result
Journey are as follows:
The medical behavior representation that patient occurs under same medical institutions, same medical serial number on the same day is once medical
Service；
Patient one day medical services number is counted；
When the medical services number that statistics obtains is compared with preset medical services frequency threshold value, if counted
The medical services number arrived is less than or equal to preset medical services frequency threshold value, then determines that the medical state of patient is normal；
If counting obtained medical services number is greater than preset medical services number, determine the medical state of patient for fraud.
Further, the step is to diagnosis, drug and prescription in the data after standardization, doctor's advice, inspection, inspection
Test, surgical data is verified mutually, and according to check results determine patient medical state process are as follows:
It is verified by disease name or nomenclature of drug；
Supplement verification is carried out by synonym；
It is verified by the upper lower class in this body surface；
The medical state that patient is determined according to check results is normal or fraud.
According to the second aspect of the embodiment of the present application, is audited automatically present invention also provides a kind of medical insurance clearing whole process and be
System comprising audit engine unit, audits unit and post audit unit in thing at advance auditing unit；The audit engine list
Member is for calculating initial data and the progress rule audit of clearing forms data and anti-cheat；
The advance auditing unit and audit engine unit carry out information exchange；The advance auditing unit is original by medical insurance
Data are sent to the audit engine unit, and the audit engine unit carries out medical insurance to the medical insurance initial data received
The advance auditing of clearing, and give the unsanctioned data feedback of advance auditing to the advance auditing unit, advance auditing is passed through
Data be sent in thing and audit unit；
Unit is audited in the thing and audit engine unit carries out information exchange；Unit is audited in the thing by advance auditing
By data be sent to audit engine unit, the audit engine unit carries out rule in thing to the data that advance auditing passes through
Audit, and the data passed through will be audited in thing and settle accounts forms data and be sent to post audit unit, to what the audit fails in thing
Data carry out artificial review；
The post audit unit and audit engine unit carry out information exchange；The post audit unit will be audited in thing
By data be sent to audit engine unit, the audit engine unit is to auditing the data passed through and clearing forms data in thing
It carries out rule audit and anti-fraud calculates；The medical insurance initial data and clearing that the post audit unit passes through according to post audit
Forms data obtains medical insurance Closing Check result；Artificial review is carried out to the unsanctioned data of post audit.
Further, the audit engine unit includes standardized module, regular auditing module and counter cheats module；
The standardized module includes that this body surface establishes module, mapping block, standardization of terminology module and standardized format
Module；Described body surface establishes module for crowd, gender, Hospital Grade, hospital category, department, doctor's rank, insurance class
Not, disease, drug, specification, dosage form, packaging packaging material, operation, inspection Various types of data establish this body surface respectively；The mapping block
For different classes of ontology data, the corresponding synonym table of ontology data is established；The standardization of terminology module extracts former number
All kinds of terms in, and all kinds of terms of extraction and synonym corresponding in synonym table are carried out to the comparison of word and word, it is right
Than obtaining corresponding pronouns, general term for nouns, numerals and measure words of such term or this pronouns, general term for nouns, numerals and measure words number after consistent；The standardized format module is used for pending
Data generate its run time format；
The rule auditing module includes extracting categorization module, rule process module, index to establish module and matching primitives
Module；The extraction categorization module is for extracting structure from three mesh of medical insurance, National Formulary management and package insert file
Change Closing Check rule and classifies；The rule process module is used for sorted structuring Closing Check rule process
At rule when operation；Culture-speculate arranges rope in regular subject name progress when the index establishes module for operation in rule
Draw, formation rule index database；Rule compares when the matching primitives module is used for data and operation by run time format
And logical operation, obtain matching result；
The anti-fraud module includes data clusters module, medical state determination module, medical services number statistical module
And correction verification module；The data clusters module is used for the standardization obtained according to consultation time and patient's name to standardized module
Data afterwards carry out data clusters；The medical state determination module be used for according to the consultation time of patient in data after cluster and
The medical state of place judgement patient；The medical services number statistical module be used for patient one day medical services number into
Row statistics, and the medical state of patient can be determined according to statistical result；The correction verification module is used for in the data after standardization
Diagnosis, drug and prescription, doctor's advice, inspection, inspection, surgical data verified mutually, and determine patient according to check results
Medical state.
According to the above-mentioned specific embodiment of the application it is found that at least having the advantages that the application passes through setting
It audits engine unit, advance auditing unit, audit unit and post audit unit in thing, can integrally cover the full mistake of medical services
Journey is truly realized prompting, mid-event control, post audit in advance.The application by by pending initial data carry out term and
The standardization of structure type will extract structuring knot from the files such as three mesh of medical insurance, National Formulary management and package insert
Auditing rule is calculated when being processed into operation and rule and establishes rule index library, rule when data and operation after standardization is subjected to word
With the matching of word, operation times can be greatly reduced, improve operation efficiency, carry out passing through word and word automatic when matching operation
The problem of with the comprehensive and accuracy being able to solve in medical insurance audit process.The medical speed that the application passes through calculating patient
Degree, on the same day in medical services number, and verified using initial data, the limitation of rule audit can be broken through, into
The anti-fraud measuring and calculating and analysis of row clearing forms data.
It is to be understood that above-mentioned general description and following specific embodiments are merely illustrative and illustrative, not
The range to be advocated of the application can be limited.
Detailed description of the invention
Following appended attached drawing is a part of the description of the present application, appended attached it illustrates embodiments herein
The principle for describing to be used to illustrate the application together of figure and specification.
Fig. 1 is the flow chart that whole process automatic auditing method is settled accounts in a kind of medical insurance that the application specific embodiment provides.
Fig. 2 is the structural frames that the automatic auditing system of whole process is settled accounts in a kind of medical insurance that the application specific embodiment provides
Figure.
Specific embodiment
For the purposes, technical schemes and advantages of the embodiment of the present application are more clearly understood, below will with attached drawing and in detail
Narration clearly illustrates the spirit of content disclosed herein, and any skilled artisan is understanding teachings herein
After embodiment, when the technology that can be taught by teachings herein, it is changed and modifies, without departing from the essence of teachings herein
Mind and range.
Illustrative embodiments of the present application and the description thereof are used to explain the present application, but is not intended as the restriction to the application.
In addition, in the drawings and embodiments the use of element/component of same or like label is for representing same or like portion
Point.
About " first " used herein, " second " ... etc., not especially censure the meaning of order or cis-position,
It is non-to limit the application, only for distinguish with same technique term description element or operation.
About direction term used herein, such as: upper and lower, left and right, front or rear etc. are only the sides with reference to attached drawing
To.Therefore, the direction term used is intended to be illustrative and not intended to limit this creation.
It is open term, i.e., about "comprising" used herein, " comprising ", " having ", " containing " etc.
Mean including but not limited to.
About it is used herein " and/or ", including any of the things or all combination.
It include " two " and " two or more " about " multiple " herein；It include " two groups " about " multiple groups " herein
And " more than two ".
About term used herein " substantially ", " about " etc., to modify it is any can with the quantity of slight change or
Error, but this slight variations or error can't change its essence.In general, slight change or mistake that such term is modified
The range of difference can be 20% in some embodiments, in some embodiments can be 10%, in some embodiments can for 5% or
It is other numerical value.It will be understood by those skilled in the art that the aforementioned numerical value referred to can be adjusted according to actual demand, not as
Limit.
It is certain to describe the word of the application by lower or discuss in the other places of this specification, to provide art technology
Personnel's guidance additional in relation to the description of the present application.
Fig. 1 is the flow chart that whole process automatic auditing method is settled accounts in a kind of medical insurance that the application specific embodiment provides.
As shown in Figure 1, medical insurance clearing whole process automatic auditing method the following steps are included:
S1, building audit engine unit, advance auditing unit, unit and post audit unit are audited in thing, wherein in advance
Unit and post audit unit are audited in audit unit, thing and carries out information exchange with audit engine unit, audit engine unit
Including standardized module, regular auditing module and counter cheat module.The building process of each module is described in detail below.
The building process of standardized module are as follows:
S111, crowd, gender, Hospital Grade, hospital category, department, doctor's rank, coverage, disease, medicine are directed to
The Various types of data such as product, specification, dosage form, packaging packaging material, operation, inspection establish this body surface respectively, wherein the data packet in this body surface
Include this pronouns, general term for nouns, numerals and measure words and this pronouns, general term for nouns, numerals and measure words number, wherein further include that disease Ontological classifications title and disease Ontological classifications are compiled in this body surface of disease
Code；It further include drug Ontological classifications title and drug Ontological classifications coding in this body surface of drug.This pronouns, general term for nouns, numerals and measure words is unique and does not repeat
The word being of practical significance.
For example, this body surface is as shown in table 1 for the crowd of crowd's foundation comprising this pronouns, general term for nouns, numerals and measure words of crowd and this pronouns, general term for nouns, numerals and measure words are numbered:
1 crowd this body surface of table
| This pronouns, general term for nouns, numerals and measure words of crowd | This pronouns, general term for nouns, numerals and measure words number |
| Old man | R001 |
| Pregnancy women | R002 |
| Children | R004 |
| Newborn | R005 |
For the disease of disease foundation, this body surface is as shown in table 2 comprising disease Ontological classifications title, disease Ontological classifications
Coding, this pronouns, general term for nouns, numerals and measure words of disease and this pronouns, general term for nouns, numerals and measure words number:
2 disease this body surface of table
For the coverage of coverage foundation, this body surface is as shown in table 3 comprising this pronouns, general term for nouns, numerals and measure words of coverage and ontology
Word number:
3 coverage this body surface of table
| This pronouns, general term for nouns, numerals and measure words of coverage | This pronouns, general term for nouns, numerals and measure words number |
| Industry and commerce insurance | S001 |
| Birth insurance | S002 |
| Medical insurance | S003 |
| Social old-age insurance | S004 |
| Unemployment insurance | S005 |
S112, for different classes of ontology data, establish the corresponding synonym table of ontology data.Wherein, synonym with
It is many-to-one relationship between this pronouns, general term for nouns, numerals and measure words, and full-text index is carried out to the synonym of disease.
For example, the crowd's synonym table established for this pronouns, general term for nouns, numerals and measure words of crowd is as shown in table 4 comprising synonym, crowd's ontology
Word and this pronouns, general term for nouns, numerals and measure words are numbered:
4 crowd's synonym table of table
| Synonym | This pronouns, general term for nouns, numerals and measure words of crowd | This pronouns, general term for nouns, numerals and measure words number |
| Age >=65 years old | Old man | R001 |
| Age < 18 year old | Children | R004 |
| Age < 36 month | Newborn | R005 |
The disease synonym table established for this pronouns, general term for nouns, numerals and measure words of disease is as shown in table 5 comprising disease synonym, disease this pronouns, general term for nouns, numerals and measure words
It is numbered with this pronouns, general term for nouns, numerals and measure words:
5 disease synonym table of table
The coverage synonym table established for this pronouns, general term for nouns, numerals and measure words of coverage is as shown in table 6 comprising insurance synonym is protected
Dangerous class body word and this pronouns, general term for nouns, numerals and measure words are numbered:
Table 6 insures synonym table
| Insure synonym | This pronouns, general term for nouns, numerals and measure words of coverage | This pronouns, general term for nouns, numerals and measure words number |
| Industrial injury danger | Industry and commerce insurance | S001 |
| Fertility danger | Birth insurance | S002 |
| Medical insurance | Medical insurance | S003 |
| Social security | Social old-age insurance | S004 |
| Unemployment | Unemployment insurance | S005 |
S113, all kinds of terms in initial data are extracted, and by the term of extraction and synonym corresponding in synonym table
The comparison of word and word is carried out, corresponding pronouns, general term for nouns, numerals and measure words of such term or this pronouns, general term for nouns, numerals and measure words number are obtained after comparison is consistent.
S114, its run time format is generated for pending data.Wherein, the run time format of pending data can
With are as follows: attribute | attribute value | affiliated attribute | #.Wherein, attribute list shows data type, and attribute value table shows the numerical value of data type, institute
Belonging to attribute indicates attribute belonging to the attribute.
For example, pending initial data are as follows: name: Zhang San, gender: male, the date of birth: on October 23rd, 1945, just
Examine the time: 2018.09.3010:10, diagnosis name: flu, drug: clarithromycin, dosage form: piece, specification: 100 * 3/ box * 2.
Utilize its run time format of the above pending Raw Data Generation are as follows:
Name | Zhang San | NULL | #；
Gender | male | NULL | #；
Crowd | the elderly | NULL | #；
Consultation time | 2018.09.3010:10 | NULL | #；
Disease | acute upper respiratory infection | NULL | #；
Nomenclature of drug | clarithromycin | NULL | #；
Pharmaceutical formulation | piece | nomenclature of drug | #；
Specification | 100 * 3 | nomenclature of drug | #；
Quantity | 2 boxes | nomenclature of drug | #.
In the present example, pharmaceutical formulation, specification and quantity belong to the attribute of a certain drug, therefore pharmaceutical formulation, rule
Lattice and the affiliated attribute of quantity are nomenclature of drug.
The building process of regular auditing module are as follows:
S121, structuring Closing Check is extracted from the files such as three mesh of medical insurance, National Formulary management and package insert
Rule, and by structuring Closing Check rule according to authenticity rule, legitimacy rule, compliance rule and reasonability rule into
Row classification.
Wherein, authenticity rule includes restriction crowd diagnosis and treatment, limits crowd's medication, limit gender diagnosis and treatment, limit gender use
Medicine etc..
Legitimacy rule includes limiting hospital grade, limiting hospital category medication, limit the medication of doctor's rank, limit doctor
Type, restriction hospital category, restriction doctor's rank etc..
Reasonability rule includes unreasonable administration route, special population medication, pharmaceutical incompatibility, unreasonable joint use
Medicine, the medication of over adaptation disease, overdose, super course for the treatment of medication, overclocking time medication etc..
Compliance rule limits idicatio medication, limits course for the treatment of medication, limit department's medication, limit insured mankind's type, limit
Determine the medication of medical insurance fund classification, limit outpatient service medication, limit be hospitalized medication, limit diagnosis and treatment medication, limit it is invalid to other drugs
Medication, limit drug combination, limit be unable to drug combination, limit compound use.
The application of structuring Closing Check rule is carried out in advance, in thing and the setting of subsequent three application stages.In general,
The stage is audited using authenticity rule and compliance rule in advance, and the problem is convenient for reminding in advance.Thing
The middle stage is audited using authenticity rule, compliance rule and reasonability rule.The subsequent stage is using authenticity rule, conjunction
Method rule, compliance rule and reasonability rule are audited.
For example, the structuring Closing Check rule and classification results extracted are as shown in table 7 comprising rule numbers, rule
Subject name, rule declaration, regular classification, regular subclass, regular source and application stage.
7 structuring Closing Check rule of table and classification results
S122, by sorted structuring Closing Check rule process at operation when rule.Wherein, structuring Closing Check
The format of rule can be with when the operation of rule are as follows: subject name | rule numbers | attribute | and calculate symbol | the corresponding value of attribute | it patrols
Collect symbol | terminating symbol |.
Wherein, subject name indicates the core subject of the rule, is mainly drug, consumptive material, operation, inspection etc..
Rule numbers indicate the unique number of every independent rules.
Attribute indicates and the data type of rule match comprising: crowd, gender, Hospital Grade, hospital category, department,
Doctor's rank, coverage, disease, drug, operation, inspection etc..
Calculating symbol indicates being greater than, being less than, being equal in rule calculating.
The corresponding value of attribute indicates the corresponding specific value of each attribute.For example, children, archiater, bronchitis etc..
Logical symbol indicates that there may be two or more sets attributes under same rule, then need to distinguish its logical relation,
That is " AND ", " OR " or " NOT " is not related to logical operation if it is single rule and then uses " NULL ".
Terminating symbol indicates the terminating symbol " # " of rule when each operation.
Below with the Ketotifen and clarithromycin both data instances in table 7, illustrate structuring Closing Check rule
The format of rule is as follows when the operation being processed into:
Ketotifen | 100002 | crowd |=| children | AND | 100002 | Hospital Grade |=| community medical service center | #
|。
Clarithromycin | 100006 | disease | include | bronchitis, pharyngitis, nasosinusitis epifolliculitis, cellulitis, erysipelas |
NULL | # | 100007 | drug | include | astemizole, Cisapride, pimozide and teldane | NULL | # |.
S123, to operation when rule in regular subject name carry out Chinese inverted index, formation rule index database, in this way
It is directly indexed and matches using rule index library when being convenient for matching primitives, to promote matching efficiency.
S124, the rule when data and operation of run time format is compared and logical operation, obtains matching result.
The building process of anti-fraud module are as follows:
S131, data clusters are carried out to the data after standardization according to consultation time and patient's name.Wherein, after standardization
Data include but is not limited to prescription data, order data, audit report, survey report and medical record data etc..
S132, the medical state that patient is determined according to the consultation time of patient in data after cluster and place comprising with
Lower step:
The latitude and longitude coordinates of the medical hospital of patient twice in succession are picked up using coordinate pick tool.
Calculate the distance between medical hospital twice in succession.
Consultation time interval is calculated by the time medical twice.
It is gone to a doctor speed using the distance between medical hospital twice in succession and consultation time interval calculation.
Medical speed is compared with preset medical velocity interval, and determines the medical shape of patient according to comparison result
State is normal, suspicious or fraud.
The decision process of patient assessment's state is specifically described using detailed embodiment below.
Set patient twice in succession go to a doctor hospital A and B latitude and longitude coordinates be respectively A (α 1, β 1), B (α 2, β 2), wherein
α indicates that longitude, β indicate latitude, then patient goes to a doctor the distance between hospital AB twice are as follows:
AB=Rarccos [cos β 1cos β 2cos (α 1- α 2)+sin β 1sin β 2]
Wherein, R indicates earth radius.
Patient is set in the consultation time of A hospital as T1, is T2 in the consultation time of B hospital, then consultation time interval T
Are as follows: T=T2-T1.
The medical speed S of patient are as follows: S=AB/T.
Medical speed S and medical velocity interval [S1, S2] are compared, if S < S1, determine that the patient's is medical
State is normal condition；If medical speed S then determines that the medical state of the patient is in medical velocity interval [S1, S2]
Suspicious state determines the medical state of the patient for fraud state if S > S2.
S133, patient one day medical services number is counted, and will the obtained medical services number of statistics and pre-
If medical services frequency threshold value be compared, according to comparison result determine patient medical state.
Wherein, the medical behavior representation one that patient occurs under same medical institutions, same medical serial number on the same day
Secondary medical services.Specifically, when the medical services number that statistics obtains being compared with preset medical services frequency threshold value,
If counting obtained medical services number is less than or equal to preset medical services frequency threshold value, the medical shape of patient is determined
State is normal；If counting obtained medical services number is greater than preset medical services number, the medical shape of patient is determined
State is fraud.
S134, the diagnosis in the data after standardization, drug and prescription, doctor's advice, inspection, inspection, surgical data carry out
Verification mutually, and according to the medical state of check results judgement patient, detailed process are as follows:
Directly verified by disease name, nomenclature of drug etc.；
Supplement verification is carried out by synonym；
It is verified by the Ontological classifications in this body surface.
The medical state that patient is determined according to check results is normal or fraud.
The data check that disease and drug are related to upper type, is illustrated by taking disease as an example below:
Assuming that initial data is " coronary heart disease " in hospital, the data obtained after medical insurance clearing are " chronic ischemic heart
Disease ".
Firstly, being " coronary by the standard words that synonym table compares to obtain initial data in hospital " coronary heart disease "
Heart disease ".
Then, the data that will be obtained after the standard words " coronary cardiopathy " of initial data in hospital and medical insurance clearing
" chronic ischemic heart disease " compares, and the two is inconsistent not to be determined as there is fraud immediately.
Finally, obtaining standard words " the coronary heart of initial data in hospital according to initial data Standard lexicon
The corresponding upper class word " chronic ischemic heart disease " of disease ", the upper class word " chronic ischemic heart disease " that will acquire and medical insurance are settled accounts
The data " chronic ischemic heart disease " obtained afterwards compare, and the two is consistent, determine patient medical state be it is normal, without taking advantage of
Swindleness behavior.
S2, advance auditing unit obtain patient medical initial data, and the medical initial data that will acquire be sent to it is careful
Core engine unit, audit engine unit is using standardized module by original data processing at standardized data, audit engine list
Rule when standardized data and operation is carried out the matching primitives of word and word using regular auditing module by member, obtains matching knot
Fruit.Wherein, regular auditing module is using authenticity rule and compliance rule.Audit engine unit advance auditing is unsanctioned
Data feedback gives advance auditing unit, and does prompting processing；The data that audit engine unit passes through advance auditing are sent to thing
Middle audit unit.
Unit being audited in S3, thing, the data that the advance auditing received passes through being sent to audit engine unit, audit is drawn
It holds up unit and is processed into standardized data using the data that standardized module passes through advance auditing, audit engine unit utilizes rule
Then rule when standardized data and operation is carried out the matching primitives of word and word by auditing module, obtains matching result.Wherein, it advises
Then auditing module is using authenticity rule, compliance rule and reasonability rule.Knot is generated for auditing the data passed through in thing
Forms data is calculated, engine unit is audited by the data passed through are audited in the clearing forms data and thing of generation and is all sent to post audit list
Member.Artificial review is carried out for the data that the audit fails in thing.Data feedback still unsanctioned for artificial review is in advance
Audit unit re-starts audit, while being deposited into database, and for statistical analysis.
S4, post audit unit are sent to audit engine unit for the data passed through are audited in the thing received, and audit is drawn
It holds up unit and will audit the data passed through in thing using standardized module and be processed into standardized data, audit engine unit utilizes rule
Then rule when standardized data and operation is carried out the matching primitives of word and word by auditing module, obtains matching result.Wherein, it advises
Then auditing module is using authenticity rule, compliance rule, reasonability rule and legitimacy rule.
Audit clearing forms data, original prescription, doctor's advice, inspection of the engine unit using anti-fraud module to patient on the same day
Look into, examine, the data such as medical record are clustered, then carry out that time and location fraud calculates, medical services number calculates, data are consistent
Property calculate, and according to calculated result determine patient medical state be it is normal, suspicious or fraud.
The medical insurance initial data and clearing forms data passed through for post audit obtains medical insurance Closing Check result.For thing
The medical insurance initial data and clearing forms data that the audit fails afterwards carry out artificial review.Data still unacceptable for artificial review
Correspondence takes the processing modes such as warning, punishment.It stores simultaneously for the still unacceptable data of artificial review into database, goes forward side by side
Row statistical analysis.
The application is by auditing unit and post audit unit, energy in setting audit engine unit, advance auditing unit, thing
Enough whole covering medical services overall processes, are truly realized prompting, mid-event control, post audit in advance.The application passes through will be pending
The initial data of core carries out the standardization of term and structure type, will be from three mesh of medical insurance, National Formulary management and package insert
Structuring Closing Check rule process is extracted in equal files into rule when operation and establishes rule index library, after standardization
Rule carries out the matching of word and word when data and operation, can greatly reduce operation times, improves operation efficiency, is matched
The problem of comprehensive and accuracy in medical insurance audit process is able to solve by word and word Auto-matching when operation.This Shen
Please by calculate patient medical speed, on the same day in medical services number, and verified using initial data, can
The limitation for breaking through rule audit carries out the anti-fraud measuring and calculating and analysis of clearing forms data.
Fig. 2 is a kind of structural representation for medical insurance clearing automatic auditing system of whole process that the application specific embodiment provides
Figure.As shown in Fig. 2, the medical insurance clearing automatic auditing system of whole process in audit engine unit 1, advance auditing unit 2, thing including examining
Nuclear unit 3 and post audit unit 4.Wherein, audit engine unit 1 is used to carry out rule to initial data and clearing forms data to examine
Core and anti-fraud calculate.
Advance auditing unit 2 and audit engine unit 1 carry out information exchange, and advance auditing unit 2 is by medical insurance initial data
It is sent to audit engine unit 1, audit engine unit 1 carries out medical insurance clearing in advance to the medical insurance initial data received
The unsanctioned data feedback of advance auditing is given and is examined in advance by audit, data unsanctioned for advance auditing, audit engine unit 1
Nuclear unit 2 goes forward side by side and acts preceding prompting；Audit unit 3 in thing is then transmitted to for the data that advance auditing passes through.
Unit 3 is audited in thing and audit engine unit 1 carries out information exchange, and audit unit 3 passes through advance auditing in thing
Data be sent to audit engine unit 1, the data that audit engine unit 1 passes through advance auditing carry out rule in thing and audit,
Post audit unit 4 is transmitted to for auditing the data passed through and clearing forms data in thing.For the number that the audit fails in thing
According to artificial review is carried out, data still unacceptable for artificial review are fed back to advance auditing unit 2 and re-start in advance
Audit, meanwhile, data still unacceptable for artificial review are stored into database, and for statistical analysis.It specifically, can be with
Counted according to rule, count according to the doctor that sees and treat patients, counted according to department, being counted according to diagnosis, according to
Drug is counted, is counted according to medical item, and statistical result is stored in database.
Post audit unit 4 and audit engine unit 1 carry out information exchange, and post audit unit 4 passes through audit in thing
Data and clearing forms data be sent to audit engine unit 1, audit engine unit 1 is to auditing the data and clearing passed through in thing
Forms data carries out subsequent rule audit and anti-fraud calculates, and the data and clearing forms data passed through for post audit obtain medical insurance
Closing Check result.Data unsanctioned for post audit and clearing forms data carry out artificial review.Still for artificial review
Unacceptable data correspondence takes the processing modes such as warning, punishment.Simultaneously for the still unacceptable data of artificial review store to
In database, and it is for statistical analysis.Specifically, can be counted according to rule, be counted according to the doctor that sees and treat patients, according to
Department is counted, is counted according to diagnosis, is counted according to drug, is counted according to medical item, and will statistics
As a result it is stored in database.
The application medical insurance settle accounts the automatic auditing system of whole process by setting audit engine unit 1, advance auditing unit 2,
Unit 3 and post audit unit 4 are audited in thing, can integrally cover the overall process of medical services, are truly realized prompting, thing in advance
Middle control and post audit.
In the present embodiment, audit engine unit 1 includes standardized module 11, regular auditing module 12 and counter cheats module
13.Wherein, standardized module 11 carries out data normalization to initial data, and the data after standardization enter regular auditing module 12
With anti-fraud module 13.Whether the data after 12 pairs of regular auditing module standardization determine with the regular storehouse matching of generation,
Obtain regular auditing result.Anti- fraud module 13 whether there is fraud according to medical state of the standardized data to patient
Determined, obtains instead cheating result.Wherein, when standardized module 11 carries out data normalization to initial data, including to original
Beginning data carry out standardization of terminology and structure type standardization.
Specifically, standardized module 11 includes that this body surface establishes module 111, mapping block 112, standardization of terminology module
11311 and standardized format module 11411.
This body surface establishes module 111 for crowd, gender, Hospital Grade, hospital category, department, doctor's rank, insurance class
Not, the Various types of data such as disease, drug, specification, dosage form, packaging packaging material, operation, inspection establish this body surface respectively.
Mapping block 112 is directed to different classes of ontology data, establishes the corresponding synonym table of ontology data.Wherein, together
It is many-to-one relationship between adopted word and this pronouns, general term for nouns, numerals and measure words, and full-text index is carried out to the synonym of disease.
Standardization of terminology module 11311 extracts all kinds of terms in former data, and by all kinds of terms and synonym of extraction
Corresponding synonym carries out the comparison of word and word in table, and corresponding pronouns, general term for nouns, numerals and measure words of such term is obtained after comparison is consistent or this pronouns, general term for nouns, numerals and measure words is compiled
Number.Standardization of terminology module 11311 is for being standardized all kinds of terms in former data.
Standardized format module 11411, can be to terminology standard for generating its run time format to pending data
The structure type of data after change is formatted.Wherein, the run time format of pending data can be with are as follows: attribute | attribute
Value | affiliated attribute | #.Wherein, attribute list shows data type, and attribute value table shows that the numerical value of data type, affiliated attribute indicate the category
Attribute belonging to property.
Specifically, regular auditing module 12 includes extracting categorization module 121, rule process module 122, index to establish module
123 and matching primitives module 124.
Wherein, categorization module 121 is extracted for mentioning from the files such as three mesh of medical insurance, National Formulary management and package insert
Structuring Closing Check rule is taken out, and by structuring Closing Check rule according to authenticity rule, legitimacy rule, compliance
Rule and reasonability rule are classified.
Rule process module 122 is used for sorted structuring Closing Check rule process into rule when operation, wherein
The format of rule can be with when the operation of structuring Closing Check rule are as follows: subject name | rule numbers | attribute | and calculate symbol | belong to
The corresponding value of property | logical symbol | # |.
Wherein, subject name indicates the core subject of the rule, is mainly drug, consumptive material, operation, inspection etc..
Rule numbers indicate the unique number of every independent rules.
Attribute indicates and the data type of rule match comprising: crowd, gender, Hospital Grade, hospital category, department,
Doctor's rank, coverage, disease, drug, operation, inspection etc..
Calculating symbol indicates being greater than, being less than, being equal in rule calculating.
The corresponding value of attribute indicates the corresponding specific value of each attribute.For example, children, archiater, bronchitis etc..
Logical symbol indicates that there may be two or more sets attributes under same rule, then need to distinguish its logical relation,
That is " AND ", " OR " or " NOT " is not related to logical operation if it is single rule and then uses " NULL ".
Terminating symbol indicates the terminating symbol " # " of rule when each operation.
Regular subject name when index establishes module 123 for operation in rule carries out Chinese inverted index, is formed
Rule index library is directly indexed and matches using rule index library when being convenient for matching primitives, to promote matching efficiency.
Matching primitives module 124 is used to compare rule when the data and operation of run time format and logical operation,
Obtain matching result.
Specifically, anti-fraud module 13 includes data clusters module 131, medical state determination module 132, medical services time
Number statistical module 133 and correction verification module 134.
Wherein, data clusters module 131 is used for the mark obtained according to consultation time and patient's name to standardized module 11
Data after standardization carry out data clusters.Wherein, the data after the standardization that standardized module 11 obtains include but is not limited to locate
Number formulary evidence, order data, audit report, survey report and medical record data etc..
Medical state determination module 132 is used to determine patient's according to the consultation time of patient in data after cluster and place
Medical state.
Medical services number statistical module 133 is used to count patient one day medical services number.Wherein, patient
The medical services of medical behavior representation occurred under same medical institutions, same medical serial number for one day.It will count
To medical services number be compared with preset medical services frequency threshold value.If it is small to count obtained medical services number
In or equal to preset medical services frequency threshold value, then determine that the medical state of patient is normal, if the medical treatment that statistics obtains
Service times are greater than preset medical services number, then determine the medical state of patient for fraud.
Correction verification module 134 is used for diagnosis, drug and prescription, doctor's advice, inspection, inspection, the hand in the data after standardization
Art data are verified mutually, specifically, can be verified in the following manner:
It is directly verified by disease name, nomenclature of drug etc., supplement verification is carried out by synonym, by this body surface
In upper lower class verified.The medical state that patient is determined by check results is normal or fraud.
Engine unit 1 is audited by setting standardized module 11, pending initial data is subjected to term and structure shape
The standardization of formula；The rule process of extraction at run time format and is established into rule index by the way that regular auditing module 12 is arranged
Library is convenient for that operation times can be greatly reduced when matching primitives in this way, improves operation efficiency, carries out passing through word when matching operation
Word Auto-matching is able to solve the problem of comprehensive and accuracy in medical insurance audit process；By the way that anti-fraud module is arranged
13, the medical state of patient is determined using medical speed, medical services number and data consistent performance are enough, thus convenient
Carry out medical insurance Closing Check.
Specifically, audit engine unit 1 can be arranged on a server, advance auditing unit 2 is arranged in doctor
On work station, it is arranged in unit 3 is audited in thing in the client of medical insurance section, hospital, post audit unit 4 is arranged in medical insurance
In the client at center.It is provided on the doctor workstation of advance auditing unit 2 and is additionally provided with HIS system (hospital information management
System), doctor sends the data to setting by Webservice by the data such as HIS system prescription or doctor's advice document
There is the server of audit engine unit 1.Server carries out advance auditing to the data received, and advance auditing is unsanctioned
Data feedback is reminded in advance to doctor workstation；The data that advance auditing is passed through are sent to the client of medical insurance section, hospital
End.
The data that the advance auditing received passes through are sent to by the client of medical insurance section, hospital is provided with audit engine list
The server of member 1.Server audit in thing to the data received, and the data passed through and settlement data will be audited in thing
It is sent to the client of HI center；Artificial review is carried out for the data that the audit fails in thing, artificial review does not pass through still
Data feedback to doctor workstation, and store into database, pass through and audit unit 3 in thing and carry out mid-event control.
The client of HI center will be audited in the thing received the data passed through be sent to be provided with audit engine unit 1
Server.Server carries out post audit to the data received, specific to carry out regular audit and anti-fraud calculating.For thing
The data passed through are audited afterwards obtains medical insurance Closing Check as a result, the artificial review of data unsanctioned for post audit progress, right
It stores in the still unacceptable data of artificial review into database, and is counted.
The foregoing is merely the schematical specific embodiments of the application, before not departing from the conceptions and principles of the application
It puts, the equivalent changes and modifications that any those skilled in the art is made, should belong to the range of the application protection.
Claims (10)
1. whole process automatic auditing method is settled accounts in a kind of medical insurance, which comprises the following steps:
Building audit engine unit, audits unit and post audit unit, the advance auditing list in thing at advance auditing unit
Unit and post audit unit are audited in member, thing carries out information exchange with audit engine unit；The audit engine unit packet
It includes standardized module, regular auditing module and counter cheats module；The standardized module is for marking original medical data
Standardization, the rule auditing module are used to carry out regular audit to the data after standardization using rule when operation, described counter to take advantage of
Swindleness module is used to determine that the medical state of patient to be normal, suspicious or fraud；
The advance auditing unit obtains the medical initial data of patient, and the medical initial data that will acquire is sent to audit and draws
Unit is held up, audit engine unit is using standardized module by original data processing at standardized data, audit engine unit benefit
The matching primitives that rule when standardized data and operation is carried out to word and word with regular auditing module, obtain matching result；Institute
Regular auditing module is stated using authenticity rule and compliance rule；The audit engine unit is by the unsanctioned number of advance auditing
According to feeding back to advance auditing unit, and do prompting processing；The data that audit engine unit passes through advance auditing are sent in thing
Audit unit；
Unit is audited in the thing, the data that the advance auditing received passes through are sent to audit engine unit, audit engine list
Member is processed into standardized data using the data that standardized module passes through advance auditing, and audit engine unit is examined using rule
Rule when standardized data and operation is carried out the matching primitives of word and word by core module, obtains matching result；The rule is examined
Core module is using authenticity rule, compliance rule and reasonability rule；Advice of settlement is generated for auditing the data passed through in thing
Data audit engine unit for the data passed through are audited in the clearing forms data and thing of generation and are all sent to post audit unit；
Post audit unit will audit the data passed through and be sent to audit engine unit, audit engine unit benefit in the thing received
The data passed through will be audited in thing with standardized module and are processed into standardized data, and audit engine unit utilizes rule audit mould
Rule when standardized data and operation is carried out the matching primitives of word and word by block, obtains matching result；The rule audit mould
Block is using authenticity rule, compliance rule, reasonability rule and legitimacy rule；The medical insurance passed through for post audit is original
Data and clearing forms data obtain medical insurance Closing Check result.
2. whole process automatic auditing method is settled accounts in medical insurance according to claim 1, which is characterized in that the standardized module
Building process are as follows:
For crowd, gender, Hospital Grade, hospital category, department, doctor's rank, coverage, disease, drug, specification, agent
Type, operation, checks that Various types of data establishes this body surface respectively at packaging packaging material, and the data in described body surface include ontology word and this
Pronouns, general term for nouns, numerals and measure words number；Described pronouns, general term for nouns, numerals and measure words is the unique and unduplicated word being of practical significance；
For different classes of ontology data, the corresponding synonym table of ontology data is established；Between the synonym and this pronouns, general term for nouns, numerals and measure words
For many-to-one relationship；
All kinds of terms in initial data are extracted, and the term of extraction is subjected to word and word with synonym corresponding in synonym table
Comparison, corresponding pronouns, general term for nouns, numerals and measure words of such term or this pronouns, general term for nouns, numerals and measure words number are obtained after comparison is consistent；
Its run time format is generated for pending data；The run time format of the pending data are as follows: attribute | attribute
Value | affiliated attribute | #；The attribute list shows data type, and the attribute value table shows the numerical value of data type, the affiliated attribute
Indicate attribute belonging to the attribute.
3. whole process automatic auditing method is settled accounts in medical insurance according to claim 1, which is characterized in that regular auditing module
Building process are as follows:
Structuring Closing Check rule is extracted from three mesh of medical insurance, National Formulary management and package insert file, and will knot
Structure Closing Check rule is classified according to authenticity rule, legitimacy rule, compliance rule and reasonability rule；
By sorted structuring Closing Check rule process at rule when operation；The operation of the structuring Closing Check rule
When rule format are as follows: subject name | rule numbers | attribute | calculate symbol | the corresponding value of attribute | logical symbol | terminating symbol
|；The subject name indicates that the core subject of the rule, the rule numbers indicate the unique number of every independent rules, institute
The data type of attribute expression and rule match is stated, the symbol that calculates indicates being greater than, being less than, being equal in rule calculating, institute
Stating the corresponding value of attribute indicates the corresponding specific value of each attribute, and the logical symbol is AND, OR, NOT or NULL；It is described
Terminating symbol indicates the terminating symbol # of rule when each operation；
Regular subject name when to operation in rule carries out Chinese inverted index, formation rule index database；
The rule when data and operation of run time format is compared and logical operation, matching result is obtained.
4. whole process automatic auditing method is settled accounts in medical insurance according to claim 3, which is characterized in that the authenticity rule
Comprising limiting crowd's diagnosis and treatment, limiting crowd's medication, restriction gender diagnosis and treatment, restriction gender medication；The legitimacy rule includes limit
Determine hospital grade, limits hospital category medication, limit the medication of doctor's rank, limit clinician's types, limit hospital category, limit doctor
It is divisional other；The reasonability rule includes unreasonable administration route, special population medication, pharmaceutical incompatibility, unreasonable joint
Medication, the medication of over adaptation disease, overdose, super course for the treatment of medication, overclocking time medication；The compliance rule limits idicatio and uses
Medicine, restriction course for the treatment of medication limit department's medication, limit insured mankind's type, limit the medication of medical insurance fund classification, limit outpatient service use
Medicine limits medication of being hospitalized, limits diagnosis and treatment medication, limit the medication invalid to other drugs, limit drug combination, limiting and cannot join
It shares medicine, limit compound use.
5. whole process automatic auditing method is settled accounts in medical insurance according to claim 1, which is characterized in that the anti-fraud module
Building process are as follows:
Data clusters are carried out to the data after standardization according to consultation time and patient's name；
The medical state of patient is determined according to the consultation time of patient in data after cluster and place；
Patient one day medical services number is counted, and the medical services number that statistics is obtained and preset medical treatment take
Business frequency threshold value is compared, and the medical state of patient is determined according to comparison result；
Diagnosis, drug and prescription in data after standardization, doctor's advice, inspection, inspection, surgical data are verified mutually,
And the medical state of patient is determined according to check results.
6. whole process automatic auditing method is settled accounts in medical insurance according to claim 5, which is characterized in that the step is according to poly-
The consultation time of patient and place determine the detailed process of the medical state of patient in data after class are as follows:
The latitude and longitude coordinates of the medical hospital of patient twice in succession are picked up using coordinate pick tool；
Calculate the distance between medical hospital twice in succession；
Consultation time interval is calculated by the time medical twice；
It is gone to a doctor speed using the distance between medical hospital twice in succession and consultation time interval calculation；
Medical speed is compared with preset medical velocity interval, and is according to the medical state of comparison result judgement patient
Normally, suspicious or fraud.
7. whole process automatic auditing method is settled accounts in medical insurance according to claim 5, which is characterized in that the step is to patient
One day medical services number is counted, and the medical services number that statistics is obtained and preset medical services frequency threshold value
It is compared, the process of the medical state of patient is determined according to comparison result are as follows:
The primary medical treatment clothes of the medical behavior representation that patient occurs under same medical institutions, same medical serial number on the same day
Business；
Patient one day medical services number is counted；
When the medical services number that statistics obtains is compared with preset medical services frequency threshold value, if what statistics obtained
Medical services number is less than or equal to preset medical services frequency threshold value, then determines that the medical state of patient is normal；If
It counts obtained medical services number and is greater than preset medical services number, then determine the medical state of patient for fraud.
8. whole process automatic auditing method is settled accounts in medical insurance according to claim 5, which is characterized in that the step is to standard
The diagnosis in data, drug and prescription after change, doctor's advice, inspection, inspection, surgical data are verified mutually, and according to verification
The process of the medical state of result judgement patient are as follows:
It is verified by disease name or nomenclature of drug；
Supplement verification is carried out by synonym；
It is verified by the upper lower class in this body surface；
The medical state that patient is determined according to check results is normal or fraud.
9. the automatic auditing system of whole process is settled accounts in a kind of medical insurance, which is characterized in that including auditing engine unit, advance auditing list
Unit and post audit unit are audited in member, thing；The audit engine unit is used to carry out initial data and clearing forms data
Rule audit and anti-fraud calculate；
The advance auditing unit and audit engine unit carry out information exchange；The advance auditing unit is by medical insurance initial data
It is sent to the audit engine unit, the audit engine unit carries out medical insurance clearing to the medical insurance initial data received
Advance auditing, and by the unsanctioned data feedback of advance auditing give the advance auditing unit, the number that advance auditing is passed through
Unit is audited according to being sent in thing；
Unit is audited in the thing and audit engine unit carries out information exchange；Unit is audited in the thing to pass through advance auditing
Data be sent to audit engine unit, the audit engine unit carries out rule in thing to the data that advance auditing passes through and examines
Core, and the data passed through will be audited in thing and settle accounts forms data and be sent to post audit unit, to the number that the audit fails in thing
According to the artificial review of progress；
The post audit unit and audit engine unit carry out information exchange；The post audit unit passes through audit in thing
Data be sent to audit engine unit, the audit engine unit is to auditing the data passed through and clearing forms data carries out in thing
Rule audit and anti-fraud calculate；The medical insurance initial data and settle accounts odd number that the post audit unit passes through according to post audit
According to obtaining medical insurance Closing Check result；Artificial review is carried out to the unsanctioned data of post audit.
10. the automatic auditing system of whole process is settled accounts in medical insurance according to claim 9, which is characterized in that the audit engine
Unit includes standardized module, regular auditing module and counter cheats module；
The standardized module includes that this body surface establishes module, mapping block, standardization of terminology module and standardized format module；
Described body surface establishes module for crowd, gender, Hospital Grade, hospital category, department, doctor's rank, coverage, disease
Disease, specification, dosage form, packaging packaging material, operation, checks that Various types of data establishes this body surface respectively at drug；The mapping block is not for
Generic ontology data establishes the corresponding synonym table of ontology data；The standardization of terminology module is extracted in former data
All kinds of terms, and by the comparison of all kinds of terms of extraction and synonym corresponding in synonym table progress word and word, comparison is consistent
After obtain corresponding pronouns, general term for nouns, numerals and measure words of such term or this pronouns, general term for nouns, numerals and measure words number；The standardized format module is used for raw to pending data
At its run time format；
The rule auditing module includes extracting categorization module, rule process module, index to establish module and matching primitives module；
The extraction categorization module from three mesh of medical insurance, National Formulary management and package insert file for extracting structuring clearing
Auditing rule is simultaneously classified；The rule process module is used for sorted structuring Closing Check rule process into operation
When rule；Regular subject name when the index establishes module for operation in rule carries out Chinese inverted index, is formed
Rule index library；Rule is compared when the matching primitives module is used for data and operation by run time format transports with logic
It calculates, obtains matching result；
The anti-fraud module includes data clusters module, medical state determination module, medical services number statistical module and school
Test module；After the standardization that the data clusters module is used to obtain standardized module according to consultation time and patient's name
Data carry out data clusters；The medical state determination module is used for according to the consultation time of patient and place in data after cluster
Determine the medical state of patient；The medical services number statistical module is used to unite to patient one day medical services number
Meter, and the medical state of patient can be determined according to statistical result；The correction verification module is used for examining in the data after standardization
Disconnected, drug and prescription, doctor's advice, inspection, inspection, surgical data are verified mutually, and determine patient just according to check results
Examine state.
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