CN109523398B - Method and device for canceling information abnormality of medicines - Google Patents

Method and device for canceling information abnormality of medicines Download PDF

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CN109523398B
CN109523398B CN201811264702.5A CN201811264702A CN109523398B CN 109523398 B CN109523398 B CN 109523398B CN 201811264702 A CN201811264702 A CN 201811264702A CN 109523398 B CN109523398 B CN 109523398B
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CN109523398A (en
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张淦
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Shenzhen Ping An Medical Health Technology Service Co Ltd
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Abstract

The invention provides a method and a device for determining abnormality of drug reimbursement information, wherein the method comprises the following steps: acquiring a medicine deposit settlement request aiming at a target medicine, wherein the medicine deposit settlement request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, weight information and height information of the user in the preset state, and determining the reimbursement and accumulated reimbursement deposit of the user in the preset state in a reimbursement period of the target medicine according to the identity information and reimbursement information; determining a single medication dose according to weight information and height information and usage rules; determining a reimbursement threshold and reimbursement time limit corresponding to the target medicine according to the reimbursement amount, the medicine benefit rules and the single medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement amount; if the deposit settlement request meets the reimbursement time limit and the accumulated reimbursement deposit is greater than the reimbursement threshold, determining that the medicament deposit settlement request is abnormal, and sending out reimbursement abnormality prompt. The technical scheme of the invention can reduce cheating protection.

Description

Method and device for canceling information abnormality of medicines
Technical Field
The invention relates to the field of medical treatment, in particular to a method for determining abnormality of drug reimbursement information.
Background
With the development of society and the continuous improvement of living standard of people, people gradually accept various insurance projects, especially medical insurance for guaranteeing basic medical requirements, and are particularly valued by people. There are two main types of existing medical insurance, including social medical insurance established by countries and society and profitable commercial medical insurance established by businesses. For the user taking part in the medical insurance, when the user is ill, the user can reimburse the medical expense generated by the disease according to the claim rule of the medical insurance, thereby relieving the economic pressure generated by the illness to a certain extent.
In the current policy of claim settlement of commercial medical insurance, for some special medicines which are included in the claim settlement scope, after verifying the identity and medical qualification of the sick user, the medical structure generally provides the special medicines required by the sick user to the user, and then the medical institution performs claim settlement according to the medicines provided to the sick user and the medical insurance institution corresponding to the sick user. This may present the following problems: because some medicines have a certain giving policy (such as buying one, for example), the given medicines are practically impossible to be claiming, and medical institutions may bring the given medicines into the claiming scope, namely cheating protection, when claiming to the medical insurance institutions, so that the claiming expenditure of the medical insurance institutions is additionally increased.
Disclosure of Invention
The embodiment of the invention provides a method and a device for determining abnormality of medicine reimbursement information, which solve the problem of increased claim expenditure of a medical insurance institution caused by cheating insurance.
In a first aspect, a method for determining drug reimbursement information anomalies is provided, comprising:
Acquiring a medicine deposit balance request aiming at a target medicine, wherein the medicine deposit balance request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state;
Determining the reimbursed amount and the accumulated reimbursement amount of the preset state user in the reimbursement period of the target medicine according to the identity information and the reimbursement information of the preset state user, wherein the reimbursement amount and the accumulated reimbursement amount are the corresponding reimbursement amount of the target medicine, and the accumulated reimbursement amount of the target medicine is not cleared in the period of time corresponding to the reimbursement period;
determining the body surface area of the preset state user according to the weight information and the height information of the preset state user;
acquiring a usage rule of the target medicine, and determining a single-time medicine dosage corresponding to the preset state user according to the body surface area and the usage rule;
Acquiring a medicine benefit rule corresponding to the target medicine, determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount, the medicine benefit rule and the single medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement amount, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, wherein the medicine period is used for reflecting the treatment degree which can be achieved by the user after the medicine is used;
Determining a reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine descensus rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period;
And if the medicine deposit settlement request is in the time corresponding to the reimbursement time limit, and the accumulated reimbursement deposit is larger than the reimbursement threshold, determining that the medicine deposit settlement request is abnormal, and sending out reimbursement abnormality prompt.
In the embodiment of the invention, by judging the accumulated reimbursement amount of the target medicine and the time when settlement is carried out, whether the accumulated reimbursement amount of the target medicine exceeds the reimbursement threshold amount or not and whether the settlement time is in the service period of the used and donated medicine or not can be determined, when the accumulated reimbursement amount of the target medicine exceeds the reimbursement threshold amount and the settlement time is in the service period of the donated medicine, the reimbursement part possibly reimburses the expense of the donated medicine, and the reimbursement abnormal reminding can be sent to enable the personnel responsible for reimbursement to notice the abnormal condition, so that the condition can be verified, the cheating protection can be prevented, and the reimbursement expenditure of a medical insurance institution can be avoided to a certain extent.
With reference to the first aspect, in one possible implementation manner, the determining, according to the weight information and the height information of the preset state user, a body surface area of the preset state user includes: determining the body surface area of the user in the preset state according to the weight information, the height information and a body surface area calculation formula of the user in the preset state; wherein, the body surface area calculation formula is: body surface area = a height + b weight-c, the height units are cm, the weight units are kg, and a, b, c are constants. The body surface area of the user in the preset state can be determined by calculating by using a preset body surface area calculation formula.
With reference to the first aspect, in one possible implementation manner, determining, according to the body surface area and the usage rule, a single-dose amount corresponding to the preset state user includes: determining unit usage dosage taking body surface area as a medication unit in the usage dosage rule; and determining the product of the unit usage dose and the body surface area as a single usage dose corresponding to the preset state user. By determining the unit usage dose and the body surface area of the target medicine, the dose of the target medicine that is used by the user at one time can be determined.
With reference to the first aspect, in one possible implementation manner, the determining, according to the claimed amount, the medicine benefit-improving rule, and the single-use dose, a reimbursement threshold corresponding to the target medicine includes: determining the paid medicine period according to the medicine Huimin rule; determining the number of the paid medicines corresponding to the target medicines according to the paid medicine period and the single-use medicine dosage; determining a first fee, wherein the first fee is the total fee of the medicines corresponding to the target medicines with the paid medicine quantity; and determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount and the first sum, wherein the reimbursement threshold corresponding to the target medicine is N times of the first expense, and N is a positive integer greater than or equal to 0. The paid medicine amount is the amount of medicine that needs to be purchased at a cost, and by determining the cost and the amount of the reimbursement that is paid for purchasing the medicine of the amount that needs to be spent, the reimbursement threshold corresponding to the amount of the reimbursement that is reimbursed can be determined.
With reference to the first aspect, in a possible implementation manner, the determining, according to the reimbursement threshold and the medicine benefit people rule, a reimbursement time limit corresponding to the target medicine includes: determining the paid medicine period and the gratuitous medicine period according to the medicine Huimin rule; determining the corresponding using time length of a target medicine period, wherein the target medicine period is the sum of the paid medicine period and the gratuitous medicine period; and determining the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the use time length, wherein the reimbursement time limit is M times of the use time length, and M is a positive integer greater than or equal to 1. The total time length corresponding to the two periods is determined by determining the period of the medicine to be purchased and the period of the medicine to be presented, which are defined by the Huimin rule, and the reimbursement time limit corresponding to the target medicine can be determined by combining the time length and the reimbursement amount.
With reference to the first aspect, in one possible implementation manner, the issuing a reimbursement exception prompt further includes: determining the prompt duration of the reimbursement abnormal prompt according to the deposit settlement request and the reimbursement time limit; and unlocking the reimbursement abnormality prompt after the time period with the time length being the prompt duration time. By releasing the reimbursement exception prompt after the prompt has been continued for a period of time, drugs within the normal claims may be reimbursed.
With reference to the first aspect, in a possible implementation manner, the method further includes: determining the maximum payoff limit corresponding to the target medicine in the reimbursement period; and if the accumulated reimbursement deposit is larger than the maximum reimbursement deposit, freezing or rejecting the medicine deposit settlement request. By determining the maximum credit for a drug within a reimbursement, excessive reimbursement can be avoided, thereby preventing fraudulent conduct.
With reference to the first aspect, in a possible implementation manner, the determining a maximum payable amount corresponding to the target drug in the reimbursement period includes: determining the maximum paid medicine quantity corresponding to the target medicine in the reimbursement period according to the usage rule, the single-time medicine dosage and the medicine benefit rule; and determining the total amount of the target medicines corresponding to the maximum paid medicine amount as the maximum payoff amount of the target medicines in the reimbursement period. By determining the maximum paid medicine quantity and determining the corresponding amount of the medicine as the maximum reimbursement amount, the medicine in the normal reimbursement scope can be ensured to be reimbursed under the premise of avoiding excessive reimbursement.
With reference to the first aspect, in one possible implementation manner, the determining, according to the usage rule, a single dose, and the medicine benefit rule, a maximum paid medicine quantity corresponding to the target medicine in the reimbursement period includes: determining the total number of the medicines corresponding to the target medicines in the reimbursement period according to the single-use dosage and the usage rules; and determining the maximum paid medicine quantity corresponding to the target medicine in the reimbursement period according to the total medicine quantity and the medicine Huiming rule.
In a second aspect, there is provided an apparatus for determining abnormality in medication reimbursement information, comprising:
The system comprises a request acquisition module, a request processing module and a processing module, wherein the request acquisition module is used for acquiring a medicine deposit settlement request aiming at a target medicine, and the medicine deposit settlement request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state;
The deposit reimbursement determining module is used for determining the reimbursement deposit and the accumulated reimbursement deposit of the preset state user in the reimbursement period of the target medicine according to the identity information and the reimbursement information of the preset state user, wherein the reimbursement deposit and the accumulated reimbursement deposit are deposit corresponding to the target medicine, and the accumulated reimbursement deposit of the target medicine is not cleared in the period corresponding to the reimbursement period;
The body surface area determining module is used for determining the body surface area of the preset state user according to the weight information and the height information of the preset state user;
The medication dosage determining module is used for acquiring the usage dosage rule of the target medicine and determining the single medication dosage corresponding to the preset state user according to the body surface area and the usage dosage rule;
the threshold limit determining module is used for obtaining a medicine benefit rule corresponding to the target medicine, determining a reimbursement threshold corresponding to the target medicine according to the reimbursement limit, the medicine benefit rule and the single medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement limit, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, and the medicine period is used for reflecting the treatment degree which can be reached after the user uses the medicine;
The reimbursement time limit determining module is used for determining reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine benefit citizen rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period;
And the abnormality determining module is used for determining that the medicine deposit settlement request is abnormal if the medicine deposit settlement request is within the time corresponding to the reimbursement time limit and the accumulated reimbursement deposit is greater than the reimbursement threshold, and sending out reimbursement abnormality prompt.
In a third aspect, there is provided another apparatus for determining abnormality of medication reimbursement information, comprising a processor, a memory and a communication interface, the processor, the memory and the communication interface being interconnected, wherein the communication interface is for receiving or transmitting data, the memory is for storing application code for executing the above method by the apparatus for determining abnormality of medication reimbursement information, and the processor is configured for executing the method of the above first aspect.
In a fourth aspect, there is provided a computer storage medium storing a computer program comprising program instructions which, when executed by a processor, cause the processor to perform the method of the first aspect described above.
In the embodiment of the invention, by judging whether the current reimbursement is the expense of the donated medicine or not, when the current reimbursement is determined to be the expense of the donated medicine, the abnormal prompt is sent out, so that a person in charge of the claim can notice the abnormal condition, the condition can be verified, the cheating protection is prevented, and the claim expenditure of the medical insurance institution can be avoided to a certain extent.
Drawings
In order to more clearly illustrate the technical solutions of the embodiments of the present invention, the drawings that are needed in the embodiments will be briefly described below, and it is obvious that the drawings in the following description are only some embodiments of the present invention, and other drawings may be obtained according to these drawings without inventive effort for a person skilled in the art.
FIG. 1 is a flow chart of a method for determining abnormality of drug reimbursement information provided by an embodiment of the invention;
FIG. 2 is a flowchart of another method for determining abnormality of drug reimbursement information according to an embodiment of the present invention;
FIG. 3 is a schematic diagram of a device for determining abnormality of drug reimbursement information according to an embodiment of the present invention;
fig. 4 is a schematic diagram of a composition structure of another apparatus for determining abnormality of drug reimbursement information according to an embodiment of the present invention.
Detailed Description
The following description of the embodiments of the present invention will be made clearly and completely with reference to the accompanying drawings, in which it is apparent that the embodiments described are only some embodiments of the present invention, but not all embodiments. All other embodiments, which can be made by those skilled in the art based on the embodiments of the invention without making any inventive effort, are intended to be within the scope of the invention.
The technical scheme of the embodiment of the invention is suitable for detecting the reimbursement information abnormality of the medicines with usage rules related to the body surface area of the user.
Before describing the schemes of the embodiments of the present invention, several concepts related to the embodiments of the present invention will be described first.
1. Concept of reimbursement period
The reimbursement period refers to a period in which the amount of the payouts need to be accumulated in the corresponding period, and after the corresponding period has elapsed, the amount of the payouts needs to be cleared. In some possible implementations, the reimbursement period may be an insurance period of the medical insurance corresponding to the drug. For example, if the medical insurance corresponding to the drug has an insurance period of 1 year, the reimbursement period is 1 year.
2. Rule of medicine benefit
The medicine benefit rules corresponding to the medicines are preferential gift rules formulated for the medicines by manufacturers for manufacturing the medicines or related medical authorities (such as social security bureaus, health management departments and the like). Such as buy one gift, buy three gift, buy five gift three, etc. The medicine benefit rule may use the number of medicines as a giving unit, and the number of medicines as a giving unit refers to that the given medicines are in units of measurement when the medicines are sold. For example, when the medicine is sold, the bottle is taken as a measuring unit, and the medicine benefit people rule is to buy three bottles for one bottle and buy five bottles for one bottle; for another example, when the medicine is sold, the box is taken as a measuring unit, and the medicine benefit people rule can buy five boxes for giving three boxes, buy five boxes for giving one box, and the like. The medicine benefit rule may also use a medicine period as a giving unit, and the medicine giving unit refers to a medicine administration period of a medicine, that is, a given medicine uses a medicine period corresponding to the medicine as a unit, and the medicine period is a period of time that can reflect the degree of treatment that can be achieved after the medicine is used. For example, if the treatment degree which can be achieved by using the medicine is expressed by a period, the medicine benefit people rule is to buy three periods for one period and buy five periods for one period; for another example, the treatment degree that can be achieved by using the medicine is expressed by the treatment course, and the medicine Huimin rule is to buy five treatment courses, give three treatment courses, buy one treatment course, give one treatment course, and the like.
2. Concept of reimbursement threshold and reimbursement time limit
The reimbursement threshold is a cost threshold which is determined according to the usage rule of the medicine and the presentation rule of the medicine and is used for measuring whether the accumulated reimbursement amount is reasonable or not. The reimbursement time limit corresponds to a reimbursement threshold, and the reimbursement time limit is a time period for distinguishing the service period of the donated medicine, which is determined according to the usage rule of the medicine and the donation rule of the medicine. The time length of the time period corresponding to the reimbursement time limit is smaller than or equal to the time length of the time period corresponding to the reimbursement period. The time corresponding to the reimbursement time limit is the time reached after the starting time of the reimbursement period starts to pass the duration corresponding to the reimbursement time limit.
A reimbursement threshold and reimbursement time limit are illustrated by way of example. Assuming that the presentation rule of the medicine is to present a period for the buying period, two boxes of medicine are used for one period according to the duration of 2 months, and the unit price of one box of medicine is 500 yuan. The cancellation threshold is an integer multiple of the cost of the drug that the user needs to charge for when the user reaches the criteria for presenting the drug, i.e., (500 x 2) × 3*1, (500 x 2) × 3*2, (500 x 2) × 3*3, etc. The reimbursement time limit corresponds to a reimbursement threshold, which is an integer multiple of the time that the user needs to use for self-charging and delivery-increasing medicines when the reimbursement threshold reaches the given medicines, namely 1*2 (3+1) 1,2 (3+1), and the like.
Referring to fig. 1, fig. 1 is a flowchart of a method for determining abnormality of drug reimbursement information according to an embodiment of the present invention, as shown in the drawing, the method includes:
S101, acquiring a medicine deposit balance settlement request aiming at a target medicine, wherein the medicine deposit balance settlement request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state.
Here, the medicine deposit settlement request is a settlement request initiated by a medical structure, and the medicine deposit settlement request may be acquired by receiving a medicine deposit settlement request issued by a settlement device of a medical institution, where the medical institution may be a medical insurance point hospital, a medical insurance point pharmacy, or the like that qualifies for selling medicines to a diseased user and has a cooperative relationship with the medical insurance institution.
The target drug is a drug within the scope of claim defined in the medical insurance clause, i.e., a drug that requires the medical insurance agency to transfer its corresponding fee to the medical agency's account.
The preset state user refers to a user who suffers from a disease and needs to purchase the target medicine. The identity information of the preset state user is related information which is uniquely matched with the preset state user and is used for indicating the personal identity of the preset state user. The identity information of the preset state user may be an identification card number of the preset state user, fingerprint feature information of the preset state user, facial feature information of the preset state user, and so on.
Here, the weight information and the height information of the user in the preset state include the height information and the weight information of the user.
S102, determining the reimbursed amount and the accumulated reimbursement amount of the preset state user in the reimbursement period of the target medicine according to the identity information and the reimbursement information of the preset state user, wherein the reimbursed amount and the accumulated reimbursement amount are the corresponding reimbursements amount of the target medicine.
Here, the reimbursement period of the target medicine needs to be accumulated for the amount paid in its corresponding period, and, after the lapse of its corresponding period, a period of clearing the amount is required. The reimbursement period is the insurance period of the medical insurance corresponding to the target medicine. For example, if the insurance period of the medical insurance corresponding to the target medicine is 1 year, the reimbursement period of the target medicine is 1 year.
The amount of the claim is the cost that has been paid for the target drug from the start time of the reimbursement period, and under normal conditions (no fraudulent act exists), the amount of the claim is equal to the cost that the user may have spent purchasing the target drug during the reimbursement period.
In a specific implementation, the reimbursement amount in the reimbursement period can be determined according to the identity information of the user in the preset state, then the reimbursement amount corresponding to the reimbursement information is determined, and the sum of the reimbursement amount corresponding to the reimbursement information and the reimbursement amount is determined as the accumulated reimbursement amount in the reimbursement period.
In one possible implementation, a user reimbursement information data table for storing medicine reimbursement information of various medicines that have been reimbursed to each preset state user may be created separately for each preset state user according to the identity information of the preset state user. And determining a user reimbursement information data table corresponding to the identity information of the preset state user according to the identity information of the preset state user, acquiring the reimbursement amount corresponding to the target medicine from the user reimbursement information data table, and determining the reimbursement amount as the reimbursement amount corresponding to the preset state user in the reimbursement period of the target medicine.
For example, there are 10000 user pay information data tables, namely user pay information data tables 1 to 10000, respectively, and the user pay information data tables 1 to 10000 correspond to the identity information 1 to 10000, respectively, and if the identity information of the user in the preset state is the identity information 100, the user pay information data table 100 corresponding to the identity information 100 is determined as the user pay information data table corresponding to the user in the preset state. The user pay information data table 100 is shown in table 1:
medicine for settling claim The amount of the sum of claims
Medicine 1 The amount 1 is paid
Medicine 2 The amount of the paid 2
… …
TABLE 1
Assuming that the target medicine is medicine 2, determining that the amount 2 corresponding to the medicine 2 is the amount corresponding to the user in the preset state in the reimbursement period of the target medicine.
In another possible implementation, a medicine pay information data table for storing pay information that has been paid to each preset state user may be created for each medicine according to the medicine information of each medicine. And determining a medicine pay information data table corresponding to the target medicine according to the target medicine, acquiring the paid insurance corresponding to the identity information of the user in the preset state from the medicine pay information data table, and determining the paid insurance corresponding to the user in the preset state in the reimbursement period of the target medicine in the target medicine.
For example, if there are 1000 medicines in the claims, the medicine payment information data tables are 1000 in total, and the medicine payment information data tables 1 to 1000 correspond to the medicines 1 to 1000, respectively. Assuming that the target medicine is the medicine 125, the medicine pay information data table 125 corresponding to the medicine 125 is determined as the medicine pay information data table corresponding to the target medicine, and the medicine pay information data table 125 is shown in table 2:
User' s The amount of the sum of claims
User 1 The amount 1 is paid
User 2 The amount of the paid 2
… …
TABLE 2
Assuming that the user in the preset state is user 1, determining that the amount 1 corresponding to the user 1 is the amount corresponding to the user in the preset state in the reimbursement period of the target medicine.
S103, determining the body surface area of the preset state user according to the weight information and the height information of the preset state user.
In the embodiment of the invention, the body surface area can be obtained by a calculation formula of the body surface area, wherein the calculation formula of the body surface area can be: body surface area = 0.0061 x height information (unit: cm) +0.0128 x weight information (unit: kg) -0.1529.
S104, acquiring a usage rule of the target medicine, and determining a single medicine dosage corresponding to the preset state user according to the body surface area and the usage rule.
Here, the usage rule of the target medicine refers to a usage interval of the target medicine and a unit usage dose in which the body surface area is a medication unit. Wherein the usage interval of the target medicine refers to the time interval between the times of using the medicine twice, and the unit usage dose taking the body surface area as the administration unit refers to the dose of the unit body surface area of the medicine used once. For example, the target medicine is recombinant human vascular endothelial inhibin, and the corresponding usage rule of the recombinant human vascular endothelial inhibin is that the recombinant human vascular endothelial inhibin is taken once daily on the 1 st to 14 th days of the treatment period, is continuously taken for 14 days, has a rest for one week, and then continues the treatment of the next period. The unit dosage of the medicine taking body surface area as a medicine taking unit is 7.5 milligrams per body surface area.
In a specific implementation, a single medication dose corresponding to the preset state user can be determined according to a unit usage dose corresponding to the target medicine and a body surface area of the preset state user, wherein the single medication dose is equal to a product of the unit usage dose and the body surface area. For example, the target drug is recombinant human endostatin, the dose of recombinant human endostatin is 7.5 mg per body surface area, and the body surface area of the user in the preset state is 0.8, and then the single dose of the user in the preset state is determined to be 7.5×0.8=6 mg.
S105, acquiring a medicine benefit rule corresponding to the target medicine, and determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount, the medicine benefit rule and the single-time medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement amount, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, and the medicine period is used for reflecting the treatment degree which can be achieved after the user uses the medicine.
In the embodiment of the present invention, the rules of medicine benefit for people use the medicine period as the giving unit and the rules of medicine benefit for people use the medicine period as the giving unit can be referred to the above description. The paid medicine period is the medicine period corresponding to the medicine which needs the user to purchase at self-expense when the giving standard corresponding to the medicine benefit rule is reached. For example, the rules of medicine Huimin deliver a course of treatment for three buying courses, and the paid medicine period is 3 courses. The gratuitous medicine period is the medicine period corresponding to the medicine which is presented to the user when the presentation standard corresponding to the medicine benefit rule is met. For example, the rules of medicine Huimin send a course of treatment for buying three courses of treatment, and the gratuitous medicine period is a course of treatment.
In the embodiment of the invention, determining the reimbursement threshold corresponding to the target medicine according to the reimbursement amount, the medicine benefit rule and the single medicine dosage can be as follows: determining a paid medicine period according to the medicine Huimin rule; determining the number of the paid medicines corresponding to the target medicines according to the paid medicine period and the single-time medicine dosage; determining a first fee, wherein the first fee is the total fee of the medicines corresponding to the target medicines with the paid medicine quantity; and determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount and the first expense, wherein the reimbursement threshold corresponding to the target medicine is N times of the first expense, and N is a positive integer greater than or equal to 1.
In one possible implementation manner, under the condition that the number of times of using the medicine in each medicine period is fixed, the number of times of using the target medicine in one medicine period corresponding to the target medicine, the specification of the target medicine and the single-time medicine dosage can be determined, and the product of the number of the target medicines in one medicine period and the paid medicine period is taken as an integer upwards to be determined as the paid medicine number.
For example, the target drug is recombinant human endostatin, the specification of the recombinant human endostatin is 15 mg/branch, the paid drug period of the recombinant human endostatin is 3 periods, 14 times of target drugs are used in one period, and the single dose is 7.5×0.8=6 mg. Then the number of the target medicines in one medicine period is determined to be 14 x 6/15=5.6 bottles, and the number of the paid medicines corresponding to the target medicines is determined to beAnd (5) a bottle.
In another possible implementation, in the case where the number of times of using the medicine in each medicine period is variable, the number of times of using the target medicine in each medicine period in the paid medicine period may be determined separately, the total number bar of times of using the target medicine in the paid medicine period by the target medicine may be determined, and then the number of paid medicines in the paid medicine period may be determined according to the specification of the target medicine and the single dose.
For example, the target drug is recombinant human vascular endothelial inhibin, the specification of the recombinant human vascular endothelial inhibin is 15 mg/branch, the paid drug period of the recombinant human vascular endothelial inhibin is 3 periods, the single administration dose is 7.5 x 0.8=6 mg, wherein, the first treatment course needs to use 10 target drugs, the second treatment course needs to use 14 drugs, the third treatment course needs to use 12 drugs, and the paid drug amount is determined to be
In a specific implementation, the unit price of the target drug may be determined, the product of the unit price of the target drug and the number of paid drugs is determined as a first fee, then N times of the first fee is determined from n=1, the N times of the first fee is compared with the amount of the reimbursement until the N times of the first fee greater than or equal to the amount of the reimbursement is found, and the N times of the first fee greater than or equal to 1 amount of the reimbursement is determined as the reimbursement threshold corresponding to the target drug. For example, the amount of paid is 2000, the number of paid medicines is 3, and the first fee is 500×3=1500. When n=1, the first cost N times is 1500, and when n=2 and the first cost N times is 3000 because 1500 is smaller than 2000, 3000 is determined as the reimbursement threshold corresponding to the target drug.
S106, determining the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine Huiming rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period.
In the embodiment of the invention, the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine Huimin rule can be determined as follows: determining a paid medicine period and a gratuitous medicine period according to the medicine Huimin rule; determining the corresponding using time length of a target medicine period, wherein the target medicine period is the sum of the paid medicine period and the gratuitous medicine period; and determining the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the use time length, wherein the reimbursement time limit is M times of the use time length, and M is a positive integer greater than or equal to 1.
In one possible implementation manner, in the case where the usage interval of the medicine is fixed and the number of times of using the medicine in each medicine period is fixed, the usage period corresponding to the target medicine period may be determined according to the usage rule in such a manner that: and determining the use duration corresponding to one medicine period according to the times of using the target medicine in one medicine period corresponding to the target medicine and the use interval of the target medicine, and determining the product of the use duration and the target medicine period as the use duration corresponding to the target medicine period. For example, the number of times of using the target medicine in one course of treatment is 2, the usage interval of the target medicine is 8 weeks, the paid medicine period is 2 courses of treatment, the gratuitous medicine period is 1 course of treatment, the usage period corresponding to one medicine period is determined to be 2*8 =16 weeks, and the usage period corresponding to the target medicine period is determined to be 16× (2+1) =48 weeks.
In another possible implementation manner, when the usage interval of the medicine is not fixed, or the number of times of using the medicine in each medicine period is not fixed, the usage duration corresponding to each medicine period may be determined according to the usage rule, and the sum of the usage durations corresponding to each medicine period is determined as the usage duration corresponding to the target medicine period. For example, the paid medicine period is 2 courses, the gratuitous medicine period is 1 course, wherein the use duration corresponding to the first course is 5 weeks, the use duration corresponding to the second course is 3 weeks, the use duration corresponding to the third course is 1 week, and the use duration corresponding to the target medicine period is 9 weeks.
In specific implementation, the duration corresponding to the target medicine period can be calculated in advance according to the usage rule of the target medicine, the duration corresponding to the target medicine period is stored in advance, and when the reimbursement threshold is determined, the reimbursement time limit corresponding to the target medicine is determined according to the duration.
In a specific implementation, a ratio of the reimbursement threshold to a total cost (i.e., a first cost) of the drug corresponding to the target drug in the number of compensated drugs may be determined, M is determined as the ratio, and M times of the time period of use is determined as the reimbursement time period.
For example, if the reimbursement threshold is 3000 and the total cost of the target medicines is 1500, the ratio is 2, and the reimbursement time period is 2 times longer.
And S107, if the medicine deposit guaranteeing and settlement request is within the time corresponding to the reimbursement time limit and the accumulated reimbursement deposit is larger than the reimbursement threshold, determining that the medicine deposit guaranteeing and settlement request is abnormal, and sending out reimbursement abnormality prompt.
Here, the term that the warranty settlement request corresponds to the reimbursement time period means that the length of time from the start time of the reimbursement period to the time when the warranty settlement request for the medicine is acquired is smaller than the reimbursement time period. For example, the start time of the reimbursement period is 2018, 1 month, 1 day, 00:00, and the reimbursement time limit is 140 days, the corresponding time of the reimbursement time limit is 2018, 5 month, 22 days, 00:00, and if the medicine balance settlement request is acquired before 2018, 5 month, 22 days, 00:00, the medicine balance settlement request meets the reimbursement time limit, otherwise, the reimbursement time limit is not met.
In the specific implementation, the reimbursement abnormal prompt can be sent out through the prompt modes such as voice prompt, page popup prompt, distinguishing mark prompt and the like.
In a further implementation, when it is determined that the drug balance settlement request is abnormal, the claim settlement operation corresponding to the drug balance settlement request can be prolonged, paused or frozen. The claim settlement operation is to transfer the reimbursement amount corresponding to the reimbursement information to an account of the medical institution which initiates the medicine deposit settlement request.
Optionally, if the drug deposit balance settlement request is not within the time corresponding to the reimbursement time limit or the accumulated reimbursement deposit is smaller than the reimbursement threshold, performing a claim settlement operation according to a normal flow, and transferring reimbursement business data corresponding to the reimbursement information to a business data account of a medical institution corresponding to the drug deposit balance settlement request, namely transferring reimbursement amount corresponding to the reimbursement information to an account of the medical institution initiating the drug deposit balance settlement request.
In a further implementation, the reimbursed amount corresponding to the reimbursement information may be modified to the accumulated reimbursement amount after being transferred to an account of the medical institution that initiated the drug insurance settlement request.
In the embodiment of the invention, by judging the accumulated reimbursement amount of the target medicine and the reimbursement time limit in settlement, whether the accumulated reimbursement amount of the target medicine exceeds the reimbursement threshold limit and whether the settlement time is in the use period of the donated medicine can be determined, when the accumulated reimbursement amount of the target medicine exceeds the reimbursement threshold limit and the settlement time is in the use period of the donated medicine, the reimbursement part possibly reimburses the expense of the donated medicine, and the reimbursement abnormal prompt is sent to enable personnel responsible for reimbursement to notice the abnormal condition, so that the condition can be verified, the cheating protection can be prevented, and the reimbursement expenditure of a medical insurance institution can be avoided to a certain extent.
In some possible scenarios, when the cancel-out period of the target medicine is long, when the user in the preset state uses the finished medicine, the user needs to continue to purchase the medicine, and the medicine which is continuously purchased can be cancelled, so that after the cancel-out abnormal prompt is sent out, the cancel-out abnormal prompt can be released after a certain time, so that the user in the preset state can continue to purchase and cancel normally. Referring to fig. 2, fig. 2 is a flowchart of another method for determining abnormality of drug reimbursement information according to an embodiment of the present invention, where the method includes:
S201, acquiring a medicine deposit balance settlement request aiming at a target medicine, wherein the medicine deposit balance settlement request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state.
S202, determining the reimbursed amount and the accumulated reimbursement amount of the preset state user in the reimbursement period of the target medicine according to the identity information and the reimbursement information of the preset state user, wherein the reimbursed amount and the accumulated reimbursement amount are the corresponding reimbursement amount of the target medicine.
S203, determining the body surface area of the preset state user according to the weight information and the height information of the preset state user.
S204, acquiring a usage rule of the target medicine, and determining a single medicine dosage corresponding to the preset state user according to the body surface area and the usage rule.
S205, acquiring a medicine benefit rule corresponding to the target medicine, and determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount, the medicine benefit rule and the single-time medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement amount, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, and the medicine period is used for reflecting the treatment degree which can be achieved after the user uses the medicine.
S206, determining the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine benefit citizen rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period.
S207, if the medicine deposit settlement request is within the time corresponding to the reimbursement time limit, and the accumulated reimbursement deposit is larger than the reimbursement threshold, determining that the medicine deposit settlement request is abnormal, and sending out reimbursement abnormality prompt.
Here, the specific implementation of steps S201 to S207 may refer to the descriptions of steps S101 to S107, and will not be repeated here.
S208, determining the prompt duration of the reimbursement abnormal prompt according to the deposit settlement request and the reimbursement time limit.
In the embodiment of the invention, the mode for determining the prompt duration of the reimbursement abnormal prompt according to the medicine warranty settlement request and reimbursement time limit is as follows: and determining the prompt duration according to the time length between the acquired medicine deposit settlement request time and the initial time of the reimbursement period and the difference between the reimbursement time limit and the time length.
For example, the start time of the reimbursement period is 2018, 1 month, 1 day, 00:00, the reimbursement time limit is 140 days, the time when the medicine warranty settlement request is acquired is 2018, 2 months, 1 day, 00:00, the time between the time when the medicine warranty settlement request is acquired and the start time of the reimbursement period is determined to be 31 days, and the prompt duration is determined to be 140-31=109 days.
And S209, unlocking the reimbursement abnormal prompt after the time period with the time length being the prompt duration.
In a specific implementation, the reimbursement abnormality prompt can be released by removing an abnormality mark, a sound prompt and the like.
In a further implementation, the freezing of the claim operation corresponding to the drug deposit settlement request can be released, the drug deposit settlement request is executed, and the reimbursement information corresponding to the target drug is settled, namely, the reimbursement amount corresponding to the reimbursement information is transferred to the account of the medical institution initiating the drug deposit settlement request.
In the embodiment of the invention, after determining that the medicine deposit settlement request is abnormal and sending out the reimbursement abnormality prompt, determining the duration of the reimbursement abnormality prompt, and contacting the abnormality prompt after continuously prompting the duration, so that the medicine in the normal reimbursement scope can be normally reimbursed.
In some possible embodiments, in the method embodiment shown in fig. 1 or fig. 2, a maximum payout amount corresponding to the target drug may be determined during the reimbursement period; if the accumulated reimbursement deposit is greater than the maximum reimbursement deposit, the medication deposit settlement request is frozen or denied.
In one possible implementation, determining the maximum payoff amount of the target drug during the reimbursement period may be: determining the maximum paid medicine quantity of the target medicine in the reimbursement period according to the usage rule, the single-time medicine dosage and the medicine Huimin rule; and determining the total cost of the medicines corresponding to the target medicines with the maximum paid medicine quantity as the maximum pay amount of the target medicines in the reimbursement period.
Specifically, the specific way for determining the maximum paid medicine quantity of the target medicine in the reimbursement period according to the usage rule, the single-use medicine quantity and the medicine Huiming rule is as follows: determining the total number of the target medicines corresponding to the target medicines in the reimbursement period according to the usage rules and the single-time medicine dosage; and determining the maximum paid medicine quantity corresponding to the target medicine in the reimbursement period according to the total medicine quantity, the medicine Huimin rule and the single medicine dosage.
In a specific implementation, the number of times of use of the target drug in the reimbursement period can be determined according to the usage rule; the total number of the drugs is determined according to the number of uses, the single dose, and the specification of the target drug.
For example, the reimbursement period is one year, the target drug is infliximab for injection, the use interval of infliximab for injection is 0 week, 2 weeks, 6 weeks, (6+8) weeks, (6+16 weeks), …, (6+8 n) weeks, the single dose of infliximab for injection is 250 milligrams, the specification of infliximab for injection is 100 milligrams per bottle, the drug benefit rule of infliximab for injection is to buy three courses of treatment, each course of treatment uses the drug for 1 time, the infliximab for injection is determined to be needed to be used for 8 times in one year according to the usage rule, the maximum drug quantity is determined to be 250 x 8/100=20, and the maximum paid drug quantity is [ 20/(250 x 4/100) ]
By determining the maximum paid medicine quantity and determining the corresponding amount of the medicine as the maximum reimbursement amount, the medicine in the normal reimbursement scope can be ensured to be reimbursed under the premise of avoiding excessive reimbursement.
The method of the embodiment of the invention is described above, and the apparatus of the embodiment of the invention is described below.
Referring to fig. 3, fig. 3 is a schematic structural diagram of a device for determining abnormality of drug reimbursement information according to an embodiment of the present invention, where the device 30 includes:
A request acquisition module 301, configured to acquire a drug balance settlement request for a target drug, where the drug balance settlement request includes identity information of a user in a preset state, reimbursement information corresponding to the target drug, and weight information and height information of the user in the preset state;
A deposit and reimbursement determining module 302, configured to determine, according to the identity information of the preset state user and the reimbursement information, a reimbursement deposit and an accumulated reimbursement deposit of the preset state user in a reimbursement period of the target drug, where the reimbursement deposit and the accumulated reimbursement deposit are deposits corresponding to the target drug, and the accumulated reimbursement deposit of the target drug is not cleared in a time period corresponding to the reimbursement period;
the body surface area determining module 303 is configured to determine a body surface area of the preset state user according to the weight information and the height information of the preset state user;
The medication dosage determining module 304 is configured to obtain a usage dosage rule of the target drug, and determine a single medication dosage corresponding to the preset state user according to the body surface area and the usage dosage rule;
The threshold limit determining module 305 is configured to obtain a drug benefit rule corresponding to the target drug, and determine a reimbursement threshold corresponding to the target drug according to a reimbursement amount and the drug benefit rule, where the reimbursement threshold is greater than or equal to the reimbursement amount, and the drug benefit rule gives the target drug with a number corresponding to a preset gratuitous drug period to a preset state user after the number of purchased target drugs reaches a number corresponding to the preset gratuitous drug period, and the drug period is used for reflecting a treatment degree that can be achieved after the user uses the drug;
a reimbursement time limit determining module 306, configured to determine a reimbursement time limit corresponding to the target drug according to the reimbursement threshold and the drug benefit rule, where the reimbursement time limit is less than or equal to the reimbursement period;
And the abnormality determining module 307 is configured to determine that the medicine deposit settlement request is abnormal if the medicine deposit settlement request is within the time corresponding to the reimbursement time limit and the accumulated reimbursement deposit is greater than the reimbursement threshold, and send a reimbursement abnormality prompt.
In one possible design, the body surface area determination module 303 is specifically configured to: determining the body surface area of the user in the preset state according to the weight information, the height information and a body surface area calculation formula of the user in the preset state;
Wherein, the body surface area calculation formula is:
body surface area = a height + b weight-c, the height units are cm, the weight units are kg, and a, b, c are constants.
In one possible design, the dosage determination module 304 is specifically configured to:
Determining unit usage dosage taking body surface area as a medication unit in the usage dosage rule;
And determining the product of the unit usage dose and the body surface area as a single usage dose corresponding to the preset state user.
In one possible design, the threshold amount determining module 305 is specifically configured to:
determining the paid medicine period according to the medicine Huimin rule;
Determining the number of the paid medicines corresponding to the target medicines according to the paid medicine period and the single-use medicine dosage;
Determining a first fee, wherein the first fee is the total fee of the medicines corresponding to the target medicines with the paid medicine quantity;
And determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount and the first sum, wherein the reimbursement threshold corresponding to the target medicine is N times of the first expense, and N is a positive integer greater than or equal to 0.
In one possible design, the reimbursement time limit determination module 306 is specifically configured to:
determining the paid medicine period and the gratuitous medicine period according to the medicine Huimin rule;
determining the corresponding using time length of a target medicine period, wherein the target medicine period is the sum of the paid medicine period and the gratuitous medicine period;
And determining the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the use time length, wherein the reimbursement time limit is M times of the use time length, and M is a positive integer greater than or equal to 1.
In one possible design, the apparatus 30 further comprises:
A duration determining module 308, configured to determine a prompt duration of the reimbursement anomaly prompt according to the warranty settlement request and the reimbursement time limit;
An abnormal prompt releasing module 309, configured to unlock the reimbursement abnormal prompt after a time period having the duration of the prompt.
In one possible design, the apparatus 30 further comprises:
A maximum credit determining module 310, configured to determine a maximum payment credit corresponding to the target drug in the reimbursement period;
The request rejecting module 311 is configured to freeze or reject the drug warranty settlement request if the accumulated reimbursement warranty is greater than the maximum reimbursement count.
In one possible design, the maximum credit determination module 310 is specifically configured to:
determining the maximum paid medicine quantity corresponding to the target medicine in the reimbursement period according to the usage rule, the single-time medicine dosage and the medicine benefit rule;
and determining the total amount of the target medicines corresponding to the maximum paid medicine amount as the maximum payoff amount of the target medicines in the reimbursement period. In one possible design, the maximum credit determination module 310 is specifically configured to:
determining the total number of the medicines corresponding to the target medicines in the reimbursement period according to the single-use dosage and the usage rules;
And determining the maximum paid medicine quantity corresponding to the target medicine in the reimbursement period according to the total medicine quantity and the medicine Huiming rule.
It should be noted that, in the embodiment corresponding to fig. 3, the content not mentioned may be referred to the description of the method embodiment, and will not be repeated here.
In the embodiment of the invention, the device for determining the abnormality of the drug reimbursement information can determine whether the accumulated reimbursement amount of the target drug exceeds the reimbursement threshold amount and determine whether the settlement time is in the use period of the donated drug by judging the accumulated reimbursement amount of the target drug and the settlement time, and when the accumulated reimbursement amount of the target drug exceeds the reimbursement threshold amount and the settlement time is in the use period of the donated drug, the device indicates that the reimbursement is likely to reimburse the expense of the donated drug, and sends out the reimbursement abnormality prompt to enable personnel responsible for reimbursement to notice the abnormality, so that the condition can be verified, cheating protection can be prevented, and the reimbursement of a medical insurance mechanism can be avoided from being additionally increased to a certain extent.
Referring to fig. 4, fig. 4 is a schematic structural diagram of another apparatus for determining abnormality of drug reimbursement information according to an embodiment of the present invention, where the apparatus 40 includes a processor 401, a memory 402, and a communication interface 403. The processor 401 is connected to the memory 402 and the communication interface 403, for example, the processor 401 may be connected to the memory 402 and the communication interface 403 through a bus.
The processor 401 is configured to support the apparatus for determining abnormality of medication reimbursement information to perform the corresponding function in the method for determining abnormality of medication reimbursement information described in fig. 1 or fig. 2. The processor 401 may be a central processing unit (central processing unit, CPU), a network processor (network processor, NP), a hardware chip or any combination thereof. The hardware chip may be an Application SPECIFIC INTEGRATED Circuit (ASIC), a programmable logic device (programmable logic device, PLD), or a combination thereof. The PLD may be a complex programmable logic device (complex programmable logic device, CPLD), a field-programmable gate array (FPGA) GATE ARRAY, generic array logic (GENERIC ARRAY logic, GAL), or any combination thereof.
The memory 402 stores program codes and the like. Memory 402 may include Volatile Memory (VM), such as random access memory (random access memory, RAM); the memory 402 may also include a non-volatile memory (NVM), such as read-only memory (ROM), flash memory (flash memory), a hard disk (HARD DISK DRIVE, HDD) or solid state disk (solid-state drive-STATE DRIVE, SSD); memory 402 may also include a combination of the above types of memory. In the embodiment of the present invention, the memory 402 is used for storing usage rules of the target medicine, rules of medicine benefit for people corresponding to the target medicine, and the like.
The communication interface 403 is used for transmitting or receiving data.
The processor 401 may call the program code to perform the following operations:
acquiring a medicine deposit settlement request aiming at a target medicine through a communication interface 403, wherein the medicine deposit settlement request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state;
Determining the reimbursed amount and the accumulated reimbursement amount of the preset state user in the reimbursement period of the target medicine according to the identity information and the reimbursement information of the preset state user, wherein the reimbursement amount and the accumulated reimbursement amount are the corresponding reimbursement amount of the target medicine, and the accumulated reimbursement amount of the target medicine is not cleared in the period of time corresponding to the reimbursement period;
determining the body surface area of the preset state user according to the weight information and the height information of the preset state user;
acquiring a usage rule of the target medicine, and determining a single-time medicine dosage corresponding to the preset state user according to the body surface area and the usage rule;
Acquiring a medicine benefit rule corresponding to the target medicine, determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount, the medicine benefit rule and the single medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement amount, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, wherein the medicine period is used for reflecting the treatment degree which can be achieved by the user after the medicine is used;
Determining a reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine descensus rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period;
And if the medicine deposit settlement request is in the time corresponding to the reimbursement time limit, and the accumulated reimbursement deposit is larger than the reimbursement threshold, determining that the medicine deposit settlement request is abnormal, and sending out reimbursement abnormality prompt.
It should be noted that implementation of each operation may also correspond to the corresponding description of the method embodiment shown in fig. 1 or fig. 2; the processor 401 may also cooperate with the communication interface 403 to perform other operations in the method embodiments described above.
Embodiments of the present invention also provide a computer storage medium storing a computer program comprising program instructions which, when executed by a computer, cause the computer to perform a method as described in the previous embodiments, the computer being part of the above-mentioned apparatus for determining drug reimbursement information anomalies. Such as the processor 401 described above.
Those skilled in the art will appreciate that implementing all or part of the above-described methods in accordance with the embodiments may be accomplished by way of a computer program stored on a computer readable storage medium, which when executed may comprise the steps of the embodiments of the methods described above. The storage medium may be a magnetic disk, an optical disk, a Read-Only Memory (ROM), a random-access Memory (Random Access Memory, RAM), or the like.
The foregoing disclosure is illustrative of the present invention and is not to be construed as limiting the scope of the invention, which is defined by the appended claims.

Claims (9)

1. A method of determining drug reimbursement information anomalies, comprising:
Acquiring a medicine deposit balance request aiming at a target medicine, wherein the medicine deposit balance request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state;
determining an reimbursed amount and an accumulated reimbursed amount of the preset state user in a reimbursement period of the target medicine according to the identity information of the preset state user and the reimbursement information, wherein the reimbursed amount is the cost paid for the target medicine from the starting time of the reimbursement period, the accumulated reimbursement amount is the sum of reimbursement amount corresponding to the reimbursement information and the reimbursement amount, the reimbursement amount and the accumulated reimbursement amount are the reimbursement amount corresponding to the target medicine, and the accumulated reimbursement amount of the target medicine is not cleared in a time period corresponding to the reimbursement period;
Determining the body surface area of the user in the preset state according to the weight information, the height information and the body surface area calculation formula of the user in the preset state, wherein the body surface area calculation formula is as follows:
Body surface area = a height + b weight-c, the height in cm, the weight in kg, a, b, c are constants;
acquiring a usage rule of the target medicine, and determining a single-time medicine dosage corresponding to the preset state user according to the body surface area and the usage rule;
Acquiring a medicine benefit rule corresponding to the target medicine, determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount, the medicine benefit rule and the single medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement amount, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, wherein the medicine period is used for reflecting the treatment degree which can be achieved by the user after the medicine is used;
Determining a reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine descensus rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period;
And if the medicine deposit settlement request is in the time corresponding to the reimbursement time limit, and the accumulated reimbursement deposit is larger than the reimbursement threshold, determining that the medicine deposit settlement request is abnormal, and sending out reimbursement abnormality prompt.
2. The method of claim 1, wherein determining the single dose corresponding to the preset state user according to the body surface area and the usage rules comprises:
Determining unit usage dosage taking body surface area as a medication unit in the usage dosage rule;
And determining the product of the unit usage dose and the body surface area as a single usage dose corresponding to the preset state user.
3. The method of claim 1, wherein the determining the reimbursement threshold for the target medication based on the reimbursement, the medication benefit rules, and the single use dosage comprises:
determining the paid medicine period according to the medicine Huimin rule;
Determining the number of the paid medicines corresponding to the target medicines according to the paid medicine period and the single-use medicine dosage;
Determining a first fee, wherein the first fee is the total fee of the medicines corresponding to the target medicines with the paid medicine quantity;
And determining a reimbursement threshold corresponding to the target medicine according to the reimbursement amount and the first expense, wherein the reimbursement threshold corresponding to the target medicine is N times of the first expense, and N is a positive integer greater than or equal to 0.
4. The method of claim 1, wherein the determining a reimbursement time limit corresponding to the target drug according to the reimbursement threshold and the drug benefit rules comprises:
determining the paid medicine period and the gratuitous medicine period according to the medicine Huimin rule;
determining the corresponding using time of a target medicine period, wherein the target medicine period is the sum of the paid medicine period and the gratuitous medicine period;
And determining the reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the use time length, wherein the reimbursement time limit is M times of the use time length, and M is a positive integer greater than or equal to 1.
5. The method of any one of claims 1-4, wherein after issuing the reimbursement exception prompt further comprises:
determining the prompt duration of the reimbursement abnormal prompt according to the deposit settlement request and the reimbursement time limit;
and unlocking the reimbursement abnormality prompt after the time period with the time length being the prompt duration time.
6. The method according to any one of claims 1-4, further comprising:
Determining the maximum payoff limit corresponding to the target medicine in the reimbursement period;
and if the accumulated reimbursement deposit is larger than the maximum reimbursement deposit, freezing or rejecting the medicine deposit settlement request.
7. An apparatus for determining abnormality in medication reimbursement information, comprising:
The system comprises a request acquisition module, a request processing module and a processing module, wherein the request acquisition module is used for acquiring a medicine deposit settlement request aiming at a target medicine, and the medicine deposit settlement request comprises identity information of a user in a preset state, reimbursement information corresponding to the target medicine, and weight information and height information of the user in the preset state;
The reimbursement determining module is used for determining reimbursement amount and accumulated reimbursement amount of the preset state user in a reimbursement period of the target medicine according to the identity information of the preset state user and the reimbursement information, wherein the reimbursement amount is the cost paid for the target medicine from the starting time of the reimbursement period, the accumulated reimbursement amount is the sum of reimbursement amount corresponding to the reimbursement information and the reimbursement amount, the reimbursement amount and the accumulated reimbursement amount are the reimbursement amount corresponding to the target medicine, and the accumulated reimbursement amount of the target medicine is not cleared in a time period corresponding to the reimbursement period;
the body surface area determining module is used for determining the body surface area of the user in the preset state according to the weight information, the height information and a body surface area calculation formula of the user in the preset state, wherein the body surface area calculation formula is as follows:
Body surface area = a height + b weight-c, the height in cm, the weight in kg, a, b, c are constants;
The medication dosage determining module is used for acquiring the usage dosage rule of the target medicine and determining the single medication dosage corresponding to the preset state user according to the body surface area and the usage dosage rule;
the threshold limit determining module is used for obtaining a medicine benefit rule corresponding to the target medicine, determining a reimbursement threshold corresponding to the target medicine according to the reimbursement limit, the medicine benefit rule and the single medicine dosage, wherein the reimbursement threshold is larger than or equal to the reimbursement limit, and the medicine benefit rule gives the target medicine with the number corresponding to the preset gratuitous medicine period to a preset state user after the number of the purchased target medicine reaches the number corresponding to the preset gratuitous medicine period, and the medicine period is used for reflecting the treatment degree which can be reached after the user uses the medicine;
The reimbursement time limit determining module is used for determining reimbursement time limit corresponding to the target medicine according to the reimbursement threshold and the medicine benefit citizen rule, wherein the reimbursement time limit is smaller than or equal to the reimbursement period;
And the abnormality determining module is used for determining that the medicine deposit settlement request is abnormal if the medicine deposit settlement request is within the time corresponding to the reimbursement time limit and the accumulated reimbursement deposit is greater than the reimbursement threshold, and sending out reimbursement abnormality prompt.
8. An apparatus for determining drug reimbursement information anomalies, comprising a processor, a memory, and a communication interface, the processor, memory, and communication interface being interconnected, wherein the communication interface is for transmitting data, the memory is for storing program code, and the processor is for invoking the program code to perform the method of any of claims 1-6.
9. A computer storage medium storing a computer program comprising program instructions which, when executed by a processor, cause the processor to perform the method of any of claims 1-6.
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