CN110009516A - Medical insurance intelligent checks method and system - Google Patents
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- CN110009516A CN110009516A CN201910258103.0A CN201910258103A CN110009516A CN 110009516 A CN110009516 A CN 110009516A CN 201910258103 A CN201910258103 A CN 201910258103A CN 110009516 A CN110009516 A CN 110009516A
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- 238000000034 method Methods 0.000 title claims abstract description 11
- 239000003814 drug Substances 0.000 claims abstract description 42
- 238000012216 screening Methods 0.000 claims abstract description 40
- 229940079593 drug Drugs 0.000 claims abstract description 26
- 238000012544 monitoring process Methods 0.000 claims abstract description 22
- 230000000845 anti-microbial effect Effects 0.000 claims abstract description 21
- 239000002699 waste material Substances 0.000 claims abstract description 16
- 238000000354 decomposition reaction Methods 0.000 claims abstract description 9
- 238000003745 diagnosis Methods 0.000 claims description 11
- 238000011161 development Methods 0.000 claims description 10
- 201000010099 disease Diseases 0.000 claims description 10
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 claims description 10
- 239000003550 marker Substances 0.000 claims description 5
- 238000009472 formulation Methods 0.000 claims description 3
- 239000000203 mixture Substances 0.000 claims description 3
- 241000208340 Araliaceae Species 0.000 claims 1
- 235000005035 Panax pseudoginseng ssp. pseudoginseng Nutrition 0.000 claims 1
- 235000003140 Panax quinquefolius Nutrition 0.000 claims 1
- 235000008434 ginseng Nutrition 0.000 claims 1
- 238000012550 audit Methods 0.000 description 5
- 238000011282 treatment Methods 0.000 description 4
- 230000007812 deficiency Effects 0.000 description 2
- 230000007246 mechanism Effects 0.000 description 2
- 238000012986 modification Methods 0.000 description 2
- 230000004048 modification Effects 0.000 description 2
- 238000013499 data model Methods 0.000 description 1
- 238000010586 diagram Methods 0.000 description 1
- 230000009977 dual effect Effects 0.000 description 1
- 235000013399 edible fruits Nutrition 0.000 description 1
- PCHJSUWPFVWCPO-UHFFFAOYSA-N gold Chemical compound [Au] PCHJSUWPFVWCPO-UHFFFAOYSA-N 0.000 description 1
- 239000010931 gold Substances 0.000 description 1
- 229910052737 gold Inorganic materials 0.000 description 1
- 230000036541 health Effects 0.000 description 1
- 238000011835 investigation Methods 0.000 description 1
- 230000008092 positive effect Effects 0.000 description 1
- 238000012552 review Methods 0.000 description 1
- 239000000126 substance Substances 0.000 description 1
- 230000009466 transformation Effects 0.000 description 1
- 238000012795 verification Methods 0.000 description 1
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- G—PHYSICS
- G06—COMPUTING; CALCULATING OR COUNTING
- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
- G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
- G06Q40/08—Insurance
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- G—PHYSICS
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- G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
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- G06Q50/10—Services
- G06Q50/26—Government or public services
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- G—PHYSICS
- G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
- G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
- G16H40/00—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices
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Abstract
A kind of medical insurance intelligent checks method and system include: to decompose be hospitalized rule, substandard to be admitted to hospital rule, key monitoring drug rule, antimicrobial rule and the corresponding abuse type of high cost medical institutions rule, fees policy fraud type corresponding with restriction gender and age rule is repeated, excess takes the corresponding waste type of medicine rule；Acquire medical insurance reimbursement detailed data, medical insurance reimbursement data, insured people's information data and the information for hospital data of insured people；Screening is carried out to medical insurance reimbursement detailed data, medical insurance reimbursement data, insured people's information data and information for hospital data；If screening goes out data fit decomposition, rule, substandard are admitted to hospital in hospital, and rule, key monitoring drug are regular, antimicrobial is regular or high cost medical institutions are regular, export abuse types results；It repeats fees policy if screening goes out data fit and limits gender and age rule, export fraud types results；It takes medicine regular if screening goes out data fit excess, exports waste types results.
Description
Technical field
The present invention relates to medical insurances to audit technical field, more particularly to a kind of medical insurance intelligent checks method and system.
Background technique
Demand with the development of medical science and technology, insurant to health is growing, and medical expense is constantly soaring, makes
The pressure for obtaining social medical insurance fund expenditure also constantly increases therewith.The dual duty that medical insurance is taken for giving control is aggravated
Appoint.
There is the phenomenon that fraud, abuse, waste in either government's medical insurance or commercial medical insurance.Past social security is checked
It protects and is surveyed mainly manually to spot-check, based on document examination with quotient, time-consuming, effort.Since supervisor is limited, expense gold can only be paid close attention to
Volume is higher, the case more than dosage, and can not all cases be detected with the risk of its fraud, abuse, waste.
Therefore, it is necessary to more effectively identify that medical insurance is cheated, guarantee the safety of medical insurance fund；Identification abuse and waste, pass through
Reform the means of payment or the effective managed care mechanism of other mechanisms for negotiation, improves medical insurance fund service efficiency.
Summary of the invention
The present invention time-consuming, effort for manual examination and verification of the existing technology, and positive rate is low, review efficiency is low, and pass
The problem of the problem of intelligent checks of system propose document is excessive, equally also to medical insurance department increases heavy burden and deficiency,
A kind of medical insurance intelligent checks method and system are provided.
The present invention is to solve above-mentioned technical problem by following technical proposals:
The present invention provides a kind of medical insurance intelligent checks method, it is characterized in that comprising following steps:
Step 1, policy development: formulation decomposition is regular in hospital, substandard is admitted to hospital rule, repetition fees policy, restriction gender
Medicine rule, key monitoring drug rule, antimicrobial rule and high cost medical institutions rule are taken with age rule, excess,
In, rule that decomposition is regular in hospital, substandard is admitted to hospital, key monitoring drug is regular, antimicrobial is regular and high cost medical institutions
The corresponding abuse type of rule, repeats fees policy fraud type corresponding with restriction gender and age rule, and excess takes medicine rule right
Type should be wasted；
Step 2, data acquisition: the medical insurance reimbursement of the medical insurance reimbursement detailed data, insured people of insured people is acquired
Data, insured people's information data and information for hospital data；
Step 3, data screening: number is submitted an expense account to the medical insurance reimbursement detailed data of insured people, the medical insurance of insured people
Comprehensive screening is carried out according to, insured people's information data and information for hospital data；
Step 4, result output: if screening go out data fit decompose be hospitalized rule, substandard be admitted to hospital rule, key monitoring
Drug rule, antimicrobial rule or high cost medical institutions rule, then export abuse types results；If screening goes out data symbols
It closes and repeats fees policy and limit gender and age rule, then export fraud types results；If screening goes out data fit, excess is taken
Medicine rule, then export waste types results.
Preferably, the medical insurance reimbursement detailed data of insured people includes insured people's unique identities identifier, clearing are unique
Identifier, the big catalog code of medical insurance three, the big directory name of medical insurance three, hospital expenses coding, hospital expenses title, expense category,
Unit price, quantity, amount of money etc.；
The medical insurance reimbursement data of insured people include insured people's unique identities identifier, settle accounts unique identifier, clearing
Year, effective marker, hospital's coding, hospital name, medical categories are admitted to hospital/leave hospital/Settlement Date, medical diagnosis on disease code, disease
Sick diagnosis name, medical total amount meet medical insurance amount of money etc.；
Insured people's information data includes insured people's unique identities identifier, insured type, date of birth, gender etc.；
Information for hospital data include hospital's coding, hospital name, Hospital Grade, hospital category etc..
The present invention also provides a kind of medical insurance intelligent checks systems, which is characterized in that it includes policy development module, data
Acquisition module, data screening module and result output module；
The policy development module for formulate decompose be hospitalized rule, substandard be admitted to hospital rule, repeat fees policy, limit
Qualitative rule of other and age, excess take medicine rule, key monitoring drug rule, antimicrobial rule and high cost medical institutions
It is regular, wherein rule that decomposition is regular in hospital, substandard is admitted to hospital, key monitoring drug is regular, antimicrobial is regular and high cost
The corresponding abuse type of medical institutions' rule, repeats fees policy fraud type corresponding with restriction gender and age rule, and excess takes
The corresponding waste type of medicine rule；
The medical treatment that the data acquisition module is used to acquire medical insurance the reimbursement detailed data, insured people of insured people is protected
Danger reimbursement data, insured people's information data and information for hospital data；
The data screening module is used to submit an expense account the medical insurance of insured people the medical insurance of detailed data, insured people
It submits an expense account data, insured people's information data and information for hospital data and carries out comprehensive screening；
The result output module be used for screening go out data fit decompose be hospitalized rule, substandard be admitted to hospital rule, emphasis
Output abuse types results when monitoring drug rule, antimicrobial rule or high cost medical institutions rule；Go out data in screening
Output fraud types results when meeting repetition fees policy and limiting gender and age rule；Go out data fit excess in screening
Output waste types results when taking medicine rule.
Preferably, the medical insurance reimbursement detailed data of insured people includes insured people's unique identities identifier, clearing are unique
Identifier, the big catalog code of medical insurance three, the big directory name of medical insurance three, hospital expenses coding, hospital expenses title, expense category,
Unit price, quantity, amount of money etc.；
The medical insurance reimbursement data of insured people include insured people's unique identities identifier, settle accounts unique identifier, clearing
Year, effective marker, hospital's coding, hospital name, medical categories are admitted to hospital/leave hospital/Settlement Date, medical diagnosis on disease code, disease
Sick diagnosis name, medical total amount meet medical insurance amount of money etc.；
Insured people's information data includes insured people's unique identities identifier, insured type, date of birth, gender etc.；
Information for hospital data include hospital's coding, hospital name, Hospital Grade, hospital category etc..
On the basis of common knowledge of the art, above-mentioned each optimum condition, can any combination to get the present invention it is each preferably
Example.
The positive effect of the present invention is that:
The present invention is carried out by establishing medical knowledge base, medical insurance policies library, big data model according to various regions actual conditions
Parameter adjustment, the identification being cheated, abused for medical insurance data, wasted effectively reduce the generation of medical malfeasance, mention
Rise the service efficiency of medical insurance fund.
Detailed description of the invention
Fig. 1 is the flow chart of the medical insurance intelligent checks method of present pre-ferred embodiments.
Fig. 2 is the structural block diagram of the medical insurance intelligent checks system of present pre-ferred embodiments.
Specific embodiment
In order to make the object, technical scheme and advantages of the embodiment of the invention clearer, below in conjunction with the embodiment of the present invention
In attached drawing, technical scheme in the embodiment of the invention is clearly and completely described, it is clear that described embodiment is
A part of the embodiment of the present invention, instead of all the embodiments.Based on the embodiments of the present invention, ordinary skill people
Member's every other embodiment obtained without making creative work, shall fall within the protection scope of the present invention.
As shown in Figure 1, the present embodiment provides a kind of medical insurance intelligent checks methods comprising following steps:
Step 1, policy development: formulation decomposition is regular in hospital, substandard is admitted to hospital rule, repetition fees policy, restriction gender
Medicine rule, key monitoring drug rule, antimicrobial rule and high cost medical institutions rule are taken with age rule, excess,
In, rule that decomposition is regular in hospital, substandard is admitted to hospital, key monitoring drug is regular, antimicrobial is regular and high cost medical institutions
The corresponding abuse type of rule, repeats fees policy fraud type corresponding with restriction gender and age rule, and excess takes medicine rule right
Type should be wasted.
Specific strategy is shown in Table 1:
Table 1
Wherein, coding 1 in table 1 is corresponding decomposes rule of being hospitalized, and the coding 2-6 in table 1 corresponds to substandard and is admitted to hospital rule,
Coding 7-8 in table 1, which is corresponded to, repeats fees policy, the corresponding restriction gender of the coding 9-11 in table 1 and age rule, in table 1
Coding 12-13 corresponds to excess and takes medicine regular, the corresponding key monitoring drug rule of the coding 14 in table 1, the coding 15-17 in table 1
Corresponding antimicrobial is regular, and the coding 18-23 in table 1 corresponds to high cost medical institutions rule.
Step 2, data acquisition: the medical insurance reimbursement of the medical insurance reimbursement detailed data, insured people of insured people is acquired
Data, insured people's information data and information for hospital data.
Wherein, the medical insurance reimbursement detailed data of insured people includes: insured people's unique identities identifier, and clearing are unique
Identifier, the big catalog code of medical insurance three, the big directory name of medical insurance three, hospital expenses coding, hospital expenses title, expense category,
Unit price, quantity, amount of money etc..
The medical insurance reimbursement data of insured people include: insured people's unique identities identifier, settle accounts unique identifier, knot
It calculates year, effective marker, hospital's coding, hospital name, medical categories are admitted to hospital/leave hospital/Settlement Date, medical diagnosis on disease code,
Medical diagnosis on disease title, medical total amount meet medical insurance amount of money etc..
Insured people's information data includes: insured people's unique identities identifier, insured type, date of birth, gender etc..
Information for hospital data include: hospital's coding, hospital name, Hospital Grade, hospital category etc..
Step 3, data screening: number is submitted an expense account to the medical insurance reimbursement detailed data of insured people, the medical insurance of insured people
Comprehensive screening is carried out according to, insured people's information data and information for hospital data.
Step 4, result output: if screening go out data fit decompose be hospitalized rule, substandard be admitted to hospital rule, key monitoring
Drug rule, antimicrobial rule or high cost medical institutions rule, then export abuse types results；If screening goes out data symbols
It closes and repeats fees policy and limit gender and age rule, then export fraud types results；If screening goes out data fit, excess is taken
Medicine rule, then export waste types results.
Such as: if the data that screening goes out meet 15 conditions of corresponding rule description of coding in table 1, export abuse
Types results；If the data that screening goes out meet the corresponding regular description condition of the coding 7 in table 1, fraud type knot is exported
Fruit；If the data that screening goes out meet the corresponding regular description condition of the coding 12 in table 1, waste types results are exported.
As shown in Fig. 2, the present embodiment also provides a kind of medical insurance intelligent checks system comprising policy development module 1, number
According to acquisition module 2, data screening module 3 and result output module 4.
The policy development module 1 for formulate decompose be hospitalized rule, substandard be admitted to hospital rule, repeat fees policy, limit
Qualitative rule of other and age, excess take medicine rule, key monitoring drug rule, antimicrobial rule and high cost medical institutions
It is regular, wherein rule that decomposition is regular in hospital, substandard is admitted to hospital, key monitoring drug is regular, antimicrobial is regular and high cost
The corresponding abuse type of medical institutions' rule, repeats fees policy fraud type corresponding with restriction gender and age rule, and excess takes
The corresponding waste type of medicine rule.
The medical treatment that the data acquisition module 2 is used to acquire medical insurance the reimbursement detailed data, insured people of insured people is protected
Danger reimbursement data, insured people's information data and information for hospital data.
The data screening module 3 is used to submit an expense account the medical insurance of insured people the medical insurance of detailed data, insured people
It submits an expense account data, insured people's information data and information for hospital data and carries out comprehensive screening.
The result output module 4 be used for screening go out data fit decompose be hospitalized rule, substandard be admitted to hospital rule, again
Output abuse types results when point monitoring drug rule, antimicrobial rule or high cost medical institutions rule；Go out to count in screening
According to output fraud types results when meeting repetition fees policy and limiting gender and age rule；It is super to go out data fit in screening
Output waste types results when measuring medicine rule.
By the medical insurance intelligent checks tool in knowledge based library and big data modeling, full dose screening is carried out to diagnosis and treatment data,
The range that ensure that monitoring avoids manually slipping, has saved the cost manually checked.Our company has passed through the multiple cities of audit at present
City's medical insurance data, identification fraud, waste, the suspicious actions abused provide medical insurance for medical insurance department, government and audit air control report:
Medical insurance efficiency is improved, the deficiency of medical insurance handling institution audit manpower and ability is compensated for, has pushed medical insurance audit by traditional people
Work spot-check the transformation to big data intelligent checks；Facilitate government's medical insurance or quotient to protect to carry out checking investigation, recovers medical insurance；Together
When effectively reduce the over-treatments phenomenons such as substandard is admitted to hospital, excess is made up a prescription, unlawful practice is controlled from source.
Although specific embodiments of the present invention have been described above, it will be appreciated by those of skill in the art that these
It is merely illustrative of, protection scope of the present invention is defined by the appended claims.Those skilled in the art is not carrying on the back
Under the premise of from the principle and substance of the present invention, many changes and modifications may be made, but these are changed
Protection scope of the present invention is each fallen with modification.
Claims (4)
1. a kind of medical insurance intelligent checks method, which is characterized in that itself the following steps are included:
Step 1, policy development: rule, substandard are admitted to hospital rule, repetition fees policy, restriction gender and year in hospital for formulation decomposition
Age rule, excess take medicine rule, key monitoring drug rule, antimicrobial rule and high cost medical institutions rule, wherein point
Rule that solution is regular in hospital, substandard is admitted to hospital, key monitoring drug rule, antimicrobial rule and high cost medical institutions rule are right
Type should be abused, fees policy fraud type corresponding with restriction gender and age rule is repeated, excess takes the corresponding waste of medicine rule
Type；
Step 2, data acquisition: the medical insurance for acquiring insured people submits an expense account detailed data, the medical insurance of insured people submits an expense account data,
Insured people's information data and information for hospital data；
Step 3, data screening: data, ginseng are submitted an expense account to the medical insurance reimbursement detailed data of insured people, the medical insurance of insured people
Guarantor's information data and information for hospital data carry out comprehensive screening；
Step 4, result output: if screening go out data fit decompose be hospitalized rule, substandard be admitted to hospital rule, key monitoring drug rule
Then, antimicrobial rule or high cost medical institutions rule, then export abuse types results；It repeats to receive if screening goes out data fit
Take rule and limit gender and age rule, then exports fraud types results；Take medicine regular if screening goes out data fit excess,
Output waste types results.
2. medical insurance intelligent checks method as described in claim 1, which is characterized in that the medical insurance of insured people submits an expense account detail number
According to include insured people's unique identities identifier, settle accounts unique identifier, the big catalog code of medical insurance three, the big directory name of medical insurance three,
Hospital expenses coding, hospital expenses title, expense category, unit price, quantity, amount of money etc.；
The medical insurance reimbursement data of insured people include insured people's unique identities identifier, clearing unique identifier, year of account,
Effective marker, hospital's coding, hospital name, medical categories are admitted to hospital/leave hospital/Settlement Date, medical diagnosis on disease code, medical diagnosis on disease
Title, medical total amount meet medical insurance amount of money etc.；
Insured people's information data includes insured people's unique identities identifier, insured type, date of birth, gender etc.；
Information for hospital data include hospital's coding, hospital name, Hospital Grade, hospital category etc..
3. a kind of medical insurance intelligent checks system, which is characterized in that it includes policy development module, data acquisition module, data sieve
Look into module and result output module；
The policy development module for formulate decompose be hospitalized rule, substandard be admitted to hospital rule, repeat fees policy, limit gender
Medicine rule, key monitoring drug rule, antimicrobial rule and high cost medical institutions rule are taken with age rule, excess,
In, rule that decomposition is regular in hospital, substandard is admitted to hospital, key monitoring drug is regular, antimicrobial is regular and high cost medical institutions
The corresponding abuse type of rule, repeats fees policy fraud type corresponding with restriction gender and age rule, and excess takes medicine rule right
Type should be wasted；
The data acquisition module is used to acquire the medical insurance reimbursement of the medical insurance reimbursement detailed data, insured people of insured people
Data, insured people's information data and information for hospital data；
The data screening module is used to submit an expense account detailed data to the medical insurance of insured people, the medical insurance of insured people submits an expense account number
Comprehensive screening is carried out according to, insured people's information data and information for hospital data；
The result output module be used for screening go out data fit decompose be hospitalized rule, substandard be admitted to hospital rule, key monitoring
Output abuse types results when drug rule, antimicrobial rule or high cost medical institutions rule；Go out data fit in screening
Output fraud types results when repeating fees policy and limiting gender and age rule；Going out data fit excess in screening takes medicine to advise
Output waste types results when then.
4. medical insurance intelligent checks system as claimed in claim 3, which is characterized in that the medical insurance of insured people submits an expense account detail number
According to include insured people's unique identities identifier, settle accounts unique identifier, the big catalog code of medical insurance three, the big directory name of medical insurance three,
Hospital expenses coding, hospital expenses title, expense category, unit price, quantity, amount of money etc.；
The medical insurance reimbursement data of insured people include insured people's unique identities identifier, clearing unique identifier, year of account,
Effective marker, hospital's coding, hospital name, medical categories are admitted to hospital/leave hospital/Settlement Date, medical diagnosis on disease code, medical diagnosis on disease
Title, medical total amount meet medical insurance amount of money etc.；
Insured people's information data includes insured people's unique identities identifier, insured type, date of birth, gender etc.；
Information for hospital data include hospital's coding, hospital name, Hospital Grade, hospital category etc..
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| CN110706121A (en) * | 2019-10-10 | 2020-01-17 | 北京东软望海科技有限公司 | Method and device for determining medical insurance fraud result, electronic equipment and storage medium |
| CN110782360A (en) * | 2019-10-24 | 2020-02-11 | 泰康保险集团股份有限公司 | Settlement data processing method and device, storage medium and electronic equipment |
| CN111325182A (en) * | 2020-03-19 | 2020-06-23 | 四川骏逸富顿科技有限公司 | OCR-based medical insurance reimbursement fraud detection method |
| CN111986037A (en) * | 2020-08-31 | 2020-11-24 | 平安医疗健康管理股份有限公司 | Method, device and equipment for monitoring medical insurance audit data and storage medium |
| CN111986035A (en) * | 2020-08-31 | 2020-11-24 | 平安医疗健康管理股份有限公司 | Medical insurance service auditing method, device, equipment and storage medium |
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| CN113095944A (en) * | 2020-01-09 | 2021-07-09 | 上海企健信息技术有限公司 | Insurance business payment management system and method |
| CN113469821A (en) * | 2020-03-31 | 2021-10-01 | 北京金山云网络技术有限公司 | Medical settlement method and device and electronic equipment |
| CN113658009A (en) * | 2021-07-22 | 2021-11-16 | 北京健康之家科技有限公司 | Claim settlement information processing method and device |
| CN114493894A (en) * | 2021-12-17 | 2022-05-13 | 武汉金豆医疗数据科技有限公司 | Method for monitoring medical behaviors by using medical insurance audit rule model |
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