CN110517155A - A kind of medical insurance compensates automatic accounting method and system - Google Patents
A kind of medical insurance compensates automatic accounting method and system Download PDFInfo
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- CN110517155A CN110517155A CN201910715381.4A CN201910715381A CN110517155A CN 110517155 A CN110517155 A CN 110517155A CN 201910715381 A CN201910715381 A CN 201910715381A CN 110517155 A CN110517155 A CN 110517155A
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- 238000000034 method Methods 0.000 title claims abstract description 24
- 238000004364 calculation method Methods 0.000 claims description 29
- 238000003745 diagnosis Methods 0.000 claims description 16
- 238000012545 processing Methods 0.000 claims description 7
- 238000012937 correction Methods 0.000 claims description 4
- 201000010099 disease Diseases 0.000 claims description 3
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 claims description 3
- 230000000694 effects Effects 0.000 claims description 3
- 230000005548 health behavior Effects 0.000 claims description 3
- 238000007781 pre-processing Methods 0.000 claims description 3
- 230000008569 process Effects 0.000 claims description 3
- 230000001737 promoting effect Effects 0.000 abstract 1
- 239000003814 drug Substances 0.000 description 8
- 229940079593 drug Drugs 0.000 description 8
- 238000010586 diagram Methods 0.000 description 7
- 238000012550 audit Methods 0.000 description 1
- 239000013066 combination product Substances 0.000 description 1
- 229940127555 combination product Drugs 0.000 description 1
- 238000012790 confirmation Methods 0.000 description 1
- 230000007812 deficiency Effects 0.000 description 1
- 230000006870 function Effects 0.000 description 1
- 230000036541 health Effects 0.000 description 1
- 230000006872 improvement Effects 0.000 description 1
- 238000007689 inspection Methods 0.000 description 1
- 238000012986 modification Methods 0.000 description 1
- 230000004048 modification Effects 0.000 description 1
- 238000000465 moulding Methods 0.000 description 1
- 238000000638 solvent extraction Methods 0.000 description 1
- 230000007480 spreading Effects 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
Abstract
This application discloses a kind of medical insurances to compensate automatic accounting method and system, and for the automatic accounting method the following steps are included: establishing data standard library, the data standard library is used for specification client medical treatment data；Building is graphical to compensate setting model, and the graphical compensation setting model is used for according to pacta conventa of accepting insurance, and rule is compensated in graphical setting；It is automatic to calculate level expense detail based on data standard library and graphical compensation setting model.The application carries out the abstract modeling of tree to medical act, medical treatment expense, has not only standardized the calculating basis of insurance responsibility, has also been conducive to according to practical business situation flexible expansion；The application realizes the more powerful insurance responsibility set-up function of function, supports 90% or more insurance responsibility graphically to set, conducive to promoting the use of a large area.
Description
Technical field
Field more particularly to a kind of automatic accounting method of medical insurance compensation are compensated this application involves medical insurance and are
System.
Background technique
The Claims Resolution of existing medical insurance is calculated, and is completed mostly by claims personnel's experience, artificial calculate, is worked many and diverse and go out
Error rate is high.Branch, portion attempts to introduce regulation engine, but carrying out configuration by declaration form there is still a need for professional IT personnel could complete
A small amount of automatic accounting processing, is unfavorable for being widely applied.
Therefore, the automatic accounting of Yao Shixian medical insurance responsibility, difficult point are the working process of medical basic data, declaration form
The logically setting of contributing responsibility.
Summary of the invention
To solve deficiency in the prior art, the application provides a kind of medical insurance and compensates automatic accounting method and system,
It can be based on client's medical treatment situation for complicated business health insurance, automatic calculate compensates the amount of money.
In order to achieve the above objectives, the embodiment of the present application provides a kind of medical insurance compensation automatic accounting method.
The embodiment of the present application adopts the following technical solutions:
A kind of automatic accounting method of medical insurance compensation, comprising the following steps:
Data standard library is established, the data standard library is used for specification client medical treatment data；
Building is graphical to compensate setting model, and the graphical compensation setting model is used for according to pacta conventa of accepting insurance, figure
Rule is compensated in shapeization setting；
It is automatic to calculate level expense detail based on data standard library and graphical compensation setting model.
The present invention further comprises following preferred embodiment:
It is preferably, described to establish data standard library, specifically:
Based on medical basic data, abstract health behavior and charge type, based on the medical act and expense class after being abstracted
Type establishes the data standard library of tree；
The medical treatment basic data includes three big catalogues, disease, hospital data, diagnosis and treatment mode and charge type.
Preferably, the building is graphical compensates setting model, comprising the following steps:
Insurance responsibility is abstracted to and is divided into trigger condition, calculation and limit control；
Based on it is described abstract and divide as a result, trigger condition, calculation and the limit control that building can graphically be set
Molding block；
Trigger condition, the common combinations of calculation and limit control module that can graphically set are constructed, it is described to scheme
Trigger condition, calculation and the combination of limit control module of shapeization setting constitute graphical compensation setting model；
The embedded lightweight open source regulation engine of the trigger condition, calculation and limit control module, for realizing
Insurance responsibility setting based on natural language.
Preferably, the trigger condition includes be in danger people's Association Identity, insurance risk reason, casualty effect, people society of being in danger
Breath information-preserving, medical information for hospital, diagnosis and treatment mode, charge type；
The calculation includes insured amount use, abatement control, expense is checked and approved and calculation formula；
The limit control includes frequency limit, medial demand limit, charge type limit, the shared limit of pacta conventa of accepting insurance
Volume and personnel share the Common combinations of limit.
Preferably, described based on data standard library and graphical compensation setting model, it is automatic to calculate level expense detail, packet
Include following steps:
Typing client's medical treatment data, contract dataset and information of being in danger；
Based on the data standard library established, client's medical treatment data are pre-processed, at the clarity including client's medical treatment data
Reason, correction and type identification；
Based on contract dataset and constructed graphical compensation setting model, rule is compensated in setting；
Compensation judgement is carried out based on pretreated client's medical treatment data and compensation rule, compensates calculating and limit control,
Automatic calculate compensates detail；
Result is compensated in output.
Preferably, the automatic accounting method further include: be based on branch's practical business growth data specification library.
The embodiment of the present application also provides a kind of medical insurance compensation automatic accounting system.
The embodiment of the present application adopts the following technical solutions:
A kind of automatic accounting system of medical insurance compensation, the automatic accounting system includes: recording module, data standard
Setting model, automatic accounting module and output module are graphically compensated in library；
The recording module, for typing client's medical treatment data, contract dataset and information of being in danger；
The data standard library is realized the clarity processing of client's medical treatment data, is entangled for pre-processing client's medical treatment data
Inclined and type identification；
The graphical compensation setting model, for compensating rule based on contract dataset setting；
The automatic accounting module is sentenced for compensate based on pretreated client's medical treatment data and compensation rule
Fixed, compensation calculates and limit control, automatic to calculate compensation detail；
The output module compensates result for exporting.
Preferably, the data standard library is tree, including medical act and charge type.
Preferably, the graphical compensation setting model includes the trigger condition, calculation and limit that can graphically set
Volume control module and its common combinations；
The embedded lightweight open source regulation engine of the trigger condition, calculation and limit control module, for realizing
Insurance responsibility setting based on natural language.
Preferably, the automatic accounting system further includes expansion module, for being based on branch's practical business spreading number
According to specification library.
The embodiment of the present application use at least one above-mentioned technical solution can reach it is following the utility model has the advantages that
1, the application carries out tree-shaped abstract modeling to medical act, medical treatment expense, has not only standardized the calculating of insurance responsibility
Basis is also conducive to branch according to practical business situation flexible expansion.
2, insurance responsibility is decomposed into trigger condition, calculation and limit and controls three parts by the application, and built-in normal
With combination, 90% or more insurance responsibility definition is supported.Embedded lightweight open source regulation engine simultaneously, support business personnel according to
Practical business situation carries out flexible expansion.
3, the application supports business personnel is arranged by graphic interface to compensate parameter of regularity, makes conducive to being widely applied
With.
Detailed description of the invention
The drawings described herein are used to provide a further understanding of the present application, constitutes part of this application, this Shen
Illustrative embodiments and their description please are not constituted an undue limitation on the present application for explaining the application.In the accompanying drawings:
Fig. 1 compensates the flow chart of automatic accounting method for medical insurance a kind of in the embodiment of the present application；
Fig. 2 is diagnosis and treatment mode and charge type classification schematic diagram in the embodiment of the present application；
Fig. 3 is that trigger condition module sets schematic diagram in the embodiment of the present application；
Fig. 4 is that calculation method module sets schematic diagram in the embodiment of the present application；
Fig. 5 is that limit control module sets schematic diagram in the embodiment of the present application；
Fig. 6 is that the customized schematic diagram of responsibility is compensated in the embodiment of the present application；
Fig. 7 is payout schedule schematic diagram in the embodiment of the present application；
Fig. 8 compensates the structural block diagram of automatic accounting system for medical insurance a kind of in embodiments herein.
Specific embodiment
To keep the purposes, technical schemes and advantages of the application clearer, below in conjunction with the application specific embodiment and
Technical scheme is clearly and completely described in corresponding attached drawing.Obviously, described embodiment is only the application one
Section Example, instead of all the embodiments.Based on the embodiment in the application, those of ordinary skill in the art are not doing
Every other embodiment obtained under the premise of creative work out, shall fall in the protection scope of this application.
Below in conjunction with attached drawing, the technical scheme provided by various embodiments of the present application will be described in detail.
Embodiment 1
As shown in Figure 1, a kind of medical insurance compensates automatic accounting method, comprising the following steps:
Step 1: establishing data standard library (such as establishing medical data dictionary), be used for specification client medical treatment data；
Specifically: as shown in Fig. 2, based on medical basic data (such as three big catalogues, disease, hospital data, diagnosis and treatment mode and
Charge type), abstract health behavior and charge type, based on after abstract medical act and charge type, establish tree
Data standard library；
In embodiment, the data standard library supports branch to extend leaf node, therefore, institute according to practical business situation
State automatic accounting method further include: be based on branch's practical business growth data specification library.
Step 2: building is graphical to compensate setting model, and the graphical compensation setting model is used to arrange item according to accepting insurance
Rule is compensated in money, graphical setting；
In embodiment, building described in step 2 is graphical to compensate setting model, comprising the following steps:
Step 201: insurance responsibility is abstracted to and is divided into trigger condition, calculation and limit control:
Step 202: being abstracted and divide based on step 201 as a result, constructing the trigger condition that can graphically set, calculating side
Formula and limit control module；
Step 203: being based on expertise, construct trigger condition, calculation and limit the control mould that can graphically set
The common combinations of block, the trigger condition that can graphically set, calculation and the combination of limit control module constitute graphical
Compensate setting model.
In embodiment, the trigger condition include be in danger people's Association Identity, insurance risk reason, casualty effect, be in danger people
Social security information, medical information for hospital, diagnosis and treatment mode, charge type；
The calculation includes insured amount use, abatement control, expense is checked and approved and calculation formula；
The limit control includes frequency limit, medial demand limit, charge type limit, the shared limit of pacta conventa of accepting insurance
Volume and personnel share the Common combinations of limit.
As in Figure 3-5, business personnel can by simply selecting, typing complicated contributing responsibility can be completed logically
Setting, current Graphics set-up function have supported 90% or more pacta conventa of accepting insurance to be set.
In embodiment, the embedded lightweight open source regulation engine of trigger condition, calculation and limit control module is such as schemed
Shown in 6, the regulation engine supports business personnel that the customized calculating elements of mode for calculating symbol, control is added to advise using pure Chinese character
Then with compensate algorithm, and be combined into customized compensation responsibility, to realize the rule definition based on natural language, promotion is accepted insurance about
Determine the logically setting ability of the contributing responsibility of clause；
As shown in fig. 7, customized compensation responsibility group is combined into payout schedule, payout schedule is associated with specific combination product and group
Body custom partitioning, so as to provide variety of healthcare safing solution to client.
In embodiment, the payout schedule supports duplication, is associated with pacta conventa of accepting insurance, setting audit and automatic processing mark
Note, and then the realization contributing responsibility simplicity of declaration form is easy-to-use, controlled after setting.
Step 3: it is based on data standard library and graphical compensation setting model, automatically accounting level expense detail, including with
Lower step:
Step 301: typing client's medical treatment data, contract dataset and information of being in danger；
Such as: client is in Grade III Class A hospital's Office visits, and two expenses occur: 50 yuan of diagnosis and treatment expense, certain drug takes 200
Member, social security submit an expense account 60 yuan；The declaration form of client's purchase, paying one for oneself, paying 2 100% for oneself after pacta conventa of accepting insurance agreement social security reimbursement
It compensates, 50 yuan of secondary deductible excess, drug, which takes limit, pays for 50 yuan.
Step 302: the data standard library established based on step 1 pre-processes client's medical treatment data, including client's medical treatment data
Clarity processing, correction and type identification；
Such as: according to the big catalogue of client three, determine that diagnosis and treatment expense, the social security of drug expense are included in, if diagnosis and treatment expense is included in
100%, drug expense is included in 50%, and total social security is included in are as follows: 50*100%+200*50%=150 member carries out society according to three big catalogues
It protects reimbursement to share, it is known that diagnosis and treatment expense submits an expense account 50*100%/150*60=20, and similarly drug expense has submitted an expense account 40.
Step 303: the graphical compensation setting model based on the building of contract dataset, information of being in danger and step 2, setting are compensated
Rule；
Step 304: carrying out compensation judgement based on pretreated client's medical treatment data and compensation rule, compensate calculating and limit
Volume control, automatic calculate compensate detail；
Such as:
It compensates and determines: being accepted insurance property, hospital etc. according to client identity, pacta conventa validity period of accepting insurance, pacta conventa of accepting insurance
Grade, diagnosis and treatment mode etc. carry out judgement inspection, and responsibility is compensated in confirmation.
It compensates and calculates: first calculating diagnosis and treatment expense, can compensate the amount of money is 50-20=30, it is less than deductible excess 50, therefore do not compensate, together
When deductible excess accumulative 30.Drug expense is calculated again, and can compensate the amount of money is 200-40=160, and deductible excess reduces 20, then calculating compensation is
(160-20) * 100%=140 member.
Limit control: diagnosis and treatment expense is not controlled without compensation；Drug, which takes calculating, compensates 140 yuan, and limit 50, then compensating is 50 yuan.
Step 305: output is compensated as a result, it is that diagnosis and treatment expense compensates 0 yuan that the present embodiment, which compensates result, and drug takes 50 yuan of compensation.
Since the application realizes the accounting of expense detail rank, more responsibilities of more declaration forms, more diagnosis and treatment modes, more are supported
Charge type intersects while the automation compensated is calculated, and reaches top standard in the industry.
If client buys more declaration forms, second part of declaration form pacta conventa of accepting insurance compensates range and first part of declaration form accepts insurance and arrange item
Money has intersection, because computing engines are based on detail level calculation, therefore can carry out specific secondary after the completion of first part of declaration form is compensated
It compensates.
Embodiment 2
As shown in figure 8, a kind of medical insurance compensates automatic accounting system, the automatic accounting system include: recording module,
Setting model, automatic accounting module and output module are graphically compensated in data standard library；
The recording module, for typing client's medical treatment data, contract dataset and information of being in danger；
The data standard library is realized the clarity processing of client's medical treatment data, is entangled for pre-processing client's medical treatment data
Inclined and type identification；
In embodiment, the data standard library is tree, including medical act and charge type.
The graphical compensation setting model, for based on contract dataset be in danger information setting compensate rule；
In embodiment, the graphical compensation setting model include the trigger condition that can graphically set, calculation and
Limit control module and its common combinations；
The embedded lightweight open source regulation engine of the trigger condition, calculation and limit control module, for realizing
Insurance responsibility setting based on natural language.
The automatic accounting module is sentenced for compensate based on pretreated client's medical treatment data and compensation rule
Fixed, compensation calculates and limit control, automatic to calculate compensation detail；
The output module compensates result for exporting.
In embodiment, the automatic accounting system further includes expansion module, for being extended based on branch's practical business
Data standard library.
The above description is only an example of the present application, is not intended to limit this application.For those skilled in the art
For, various changes and changes are possible in this application.All any modifications made within the spirit and principles of the present application are equal
Replacement, improvement etc., should be included within the scope of the claims of this application.
Claims (10)
1. a kind of medical insurance compensates automatic accounting method, it is characterised in that:
The automatic accounting method the following steps are included:
Data standard library is established, the data standard library is used for specification client medical treatment data；
Building is graphical to compensate setting model, and the graphical compensation setting model is used for according to pacta conventa of accepting insurance, graphically
Rule is compensated in setting；
It is automatic to calculate level expense detail based on data standard library and graphical compensation setting model.
2. a kind of medical insurance according to claim 1 compensates automatic accounting method, it is characterised in that:
It is described to establish data standard library, specifically:
Based on medical basic data, abstract health behavior and charge type, based on after abstract medical act and charge type, build
The data standard library of vertical tree；
The medical treatment basic data includes three big catalogues, disease, hospital data, diagnosis and treatment mode and charge type.
3. a kind of medical insurance according to claim 1 compensates automatic accounting method, it is characterised in that:
The building is graphical to compensate setting model, comprising the following steps:
Insurance responsibility is abstracted to and is divided into trigger condition, calculation and limit control；
Based on it is abstract and divide as a result, trigger condition, calculation and the limit control module that building can graphically be set；
The combination of the trigger condition, calculation and limit control module that can graphically set is constructed, it is described graphically to set
Trigger condition, calculation and the combination of limit control module constitute and graphical compensate setting model；
The embedded lightweight open source regulation engine of the trigger condition, calculation and limit control module, for realizing being based on
The insurance responsibility of natural language is set.
4. a kind of medical insurance according to claim 3 compensates automatic accounting method, it is characterised in that:
The trigger condition includes the people's Association Identity, insurance risk reason, casualty effect, people's social security of being in danger information, medical of being in danger
Information for hospital, diagnosis and treatment mode, charge type；
The calculation includes insured amount use, abatement control, expense is checked and approved and calculation formula；
Limit control include frequency limit, medial demand limit, charge type limit, pacta conventa of accepting insurance share limit and
Personnel share the combination of limit.
5. a kind of medical insurance according to claim 1 compensates automatic accounting method, it is characterised in that:
It is described that setting model is compensated with graphical based on data standard library, level expense detail is calculated automatically, comprising the following steps:
Typing client's medical treatment data, contract dataset and information of being in danger；
Specification library based on the data, pre-process client's medical treatment data, including client's medical treatment data clarity processing, correction and
Type identification；
Based on contract dataset and graphical compensation setting model, rule is compensated in setting；
Compensation judgement is carried out based on pretreated client's medical treatment data and compensation rule, compensates calculating and limit control, is realized
Automatic calculate compensates detail；
Result is compensated in output.
6. a kind of -5 any medical insurances compensate automatic accounting method according to claim 1, it is characterised in that:
The automatic accounting method further include: be based on branch's operation expanding data standard library.
7. a kind of medical insurance compensates automatic accounting system, it is characterised in that:
The automatic accounting system includes: recording module, data standard library, graphically compensates setting model, calculates module automatically
And output module；
The recording module, for typing client's medical treatment data, contract dataset and information of being in danger；
The data standard library, for pre-processing client's medical treatment data, realize the clarity processing of client's medical treatment data, correction and
Type identification；
The graphical compensation setting model, for compensating rule based on contract dataset setting；
The automatic accounting module, for carrying out compensation judgement based on pretreated client's medical treatment data and compensation rule, paying for
It pays to calculate and compensates detail with limit control, automatic calculate；
The output module compensates result for exporting.
8. a kind of medical insurance according to claim 7 compensates automatic accounting system, it is characterised in that:
The data standard library is tree, including medical act and charge type.
9. a kind of medical insurance according to claim 7 compensates automatic accounting system, it is characterised in that:
The graphical compensation setting model include the trigger condition that can graphically set, calculation and limit control module and
Its common combinations；
The embedded lightweight open source regulation engine of the trigger condition, calculation and limit control module, for realizing being based on
The insurance responsibility of natural language is set.
10. compensating automatic accounting system according to a kind of any medical insurance of claim 7-9, it is characterised in that:
The automatic accounting system further includes expansion module, for being based on branch's practical business growth data specification library.
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Cited By (2)
| Publication number | Priority date | Publication date | Assignee | Title |
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| CN112767066A (en) * | 2020-12-28 | 2021-05-07 | 中国人寿保险股份有限公司上海数据中心 | Student safety insurance sale system, method, equipment and storage medium |
| CN114969130A (en) * | 2022-08-01 | 2022-08-30 | 创智和宇信息技术股份有限公司 | Social insurance collection service data processing method, system and storage medium |
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