CN112330466A - Online monitoring method and device for medical insurance fund illegal operation event - Google Patents
Online monitoring method and device for medical insurance fund illegal operation event Download PDFInfo
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Abstract
The invention discloses an online monitoring method and device for medical insurance fund illegal operation events, wherein the method comprises the following steps: collecting credit event data of each medical institution, wherein the credit event data is used for reflecting whether the medical institution illegally operates the medical insurance fund; performing index quantification processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution; determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each medical institution corresponding to each preset monitoring index; and determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, wherein the credit evaluation result is used for reflecting the risk degree of illegal operation of the medical insurance fund of the medical institution. The invention can realize the on-line monitoring of the medical insurance fund illegal operation event.
Description
Technical Field
The invention relates to the technical field of internet, in particular to an online monitoring method and device for medical insurance fund illegal operation events.
Background
This section is intended to provide a background or context to the embodiments of the invention that are recited in the claims. The description herein is not admitted to be prior art by inclusion in this section.
The medical insurance fund (abbreviated as medical insurance fund) refers to the basic medical treatment of the state for guaranteeing the employees, and special funds for the basic medical insurance of the employees are raised to units and individuals by medical insurance handling organizations according to the relevant national regulations.
The conventional medical insurance fund management system cannot monitor illegal operation events of medical insurance funds on line, so that the illegal operation events of various large medical institutions frequently occur, and the phenomenon that excessive medical institutions and medical institutions share a reference maintainer to cheat on taking the medical insurance funds is rare.
In view of the above problems, no effective solution has been proposed.
Disclosure of Invention
The embodiment of the invention provides an online monitoring method for illegal operation events of medical insurance funds, which is used for solving the technical problem that the traditional medical insurance fund management system cannot monitor the illegal operation events of the medical insurance funds on line, and comprises the following steps: collecting credit event data of each medical institution, wherein the credit event data is used for reflecting whether the medical institution illegally operates the medical insurance fund; performing index quantification processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution; determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each medical institution corresponding to each preset monitoring index; and determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, wherein the credit evaluation result is used for reflecting the risk degree of illegal operation of the medical insurance fund of the medical institution.
The embodiment of the invention also provides an online monitoring device for illegal operation events of medical insurance funds, which is used for solving the technical problem that the traditional medical insurance funds management system cannot monitor the illegal operation events of the medical insurance funds on line, and comprises the following components: the data acquisition module is used for acquiring credit event data of each medical institution, wherein the credit event data is used for reflecting whether the medical institution violates the operation of the medical insurance fund; the index quantization module is used for performing index quantization processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution; the index evaluation module is used for determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each medical institution corresponding to each preset monitoring index; and the credit evaluation module is used for determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, and the credit evaluation result is used for reflecting the risk degree of the medical institution for illegal operation of the medical insurance fund.
The embodiment of the invention also provides computer equipment for solving the technical problem that the existing medical insurance fund management system cannot monitor the illegal operation events of the medical insurance fund on line.
The embodiment of the invention also provides a computer readable storage medium, which is used for solving the technical problem that the existing medical insurance fund management system cannot monitor the illegal operation events of the medical insurance fund on line.
In the embodiment of the invention, the credit event data of each medical institution is collected, the collected credit event data is subjected to index quantification processing to obtain the index value of each preset monitoring index corresponding to each medical institution, the credit evaluation score of each preset monitoring index corresponding to each medical institution is determined according to the index value of each preset monitoring index corresponding to each medical institution, and finally the credit evaluation result of each medical institution is determined according to the credit evaluation score of each preset monitoring index corresponding to each medical institution to reflect the risk degree of illegal operation of medical insurance funds of each medical institution.
According to the embodiment of the invention, the risk degree of illegal operation of the medical insurance fund of each medical institution is quantitatively evaluated according to the credit event data of each medical institution, so that the illegal operation event of the medical insurance fund can be monitored on line.
Drawings
In order to more clearly illustrate the embodiments of the present invention or the technical solutions in the prior art, the drawings used in the description of the embodiments or the prior art will be briefly described below, it is obvious that the drawings in the following description are only some embodiments of the present invention, and for those skilled in the art, other drawings can be obtained according to the drawings without creative efforts. In the drawings:
FIG. 1 is a flowchart of an online monitoring method for medical insurance fund violation operation events provided in an embodiment of the present invention;
fig. 2 is a schematic diagram illustrating a process of performing quantization processing on medical data according to an embodiment of the present invention;
fig. 3 is a schematic diagram of a process for quantifying the penalty term data according to an embodiment of the present invention;
FIG. 4 is a diagram illustrating a process for quantifying questionnaire data according to an embodiment of the present invention;
FIG. 5 is a schematic diagram of an online monitoring system for medical insurance fund violation operation events provided in an embodiment of the present invention;
FIG. 6 is a flowchart illustrating an implementation of online monitoring of medical insurance fund-to-violation events based on medical insurance bureau settlement data according to an embodiment of the present invention;
fig. 7 is a schematic view of an online monitoring device for medical insurance fund violation operation events provided in an embodiment of the present invention.
Detailed Description
In order to make the objects, technical solutions and advantages of the embodiments of the present invention more apparent, the embodiments of the present invention are further described in detail below with reference to the accompanying drawings. The exemplary embodiments and descriptions of the present invention are provided to explain the present invention, but not to limit the present invention.
The embodiment of the invention provides an online monitoring method for medical insurance fund illegal operation events, and fig. 1 is a flow chart of the online monitoring method for medical insurance fund illegal operation events provided by the embodiment of the invention, and as shown in fig. 1, the method comprises the following steps:
s101, collecting credit event data of each medical institution, wherein the credit event data is used for reflecting whether the medical institution violates operation of the medical insurance fund.
It should be noted that the credit event data collected in the embodiment of the present invention refers to various data capable of reflecting whether each medical institution violates the operation of the medical insurance fund, and includes but is not limited to: medical data of each medical institution, punishment data of the medical insurance fund supervision platform on each medical institution and questionnaire data of questionnaire objects on each medical institution are stored in the medical insurance bureau system database. Alternatively, the questionnaire object in the embodiment of the present invention may be a patient for medical treatment or a medical staff.
And S102, performing index quantification processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution.
It should be noted that, since each medical institution uploads respective medical data to the medical insurance bureau every day, the medical data uploaded to the medical insurance bureau system is huge due to the large number of medical institutions. If the calculation is directly carried out in the database of the medical insurance bureau system, on one hand, the normal service is influenced due to insufficient calculation power of the medical insurance bureau database, and on the other hand, the program can not run normally due to overlong calculation time. Thus, in one embodiment, in the case that the credit event data collected in S101 is medical data of each medical institution stored in the medical insurance system database, S102 may be implemented by: loading medical data of each medical institution stored in a medical insurance bureau system database into an Elasticissearch engine by adopting a Logstash tool; and performing aggregation processing on the medical data from each medical institution based on an Elasticissearch engine to obtain credit event data of each medical institution.
As shown in fig. 2, in the embodiment of the present invention, a Logstash tool is used to load data of the medical insurance bureau system into an Elasticsearch engine, and then perform data aggregation operation, which not only facilitates lateral expansion, but also can shield differences between different databases at the medical insurance bureau end. And aiming at different databases, only the data source in the configuration file needs to be modified.
According to the temporary supervision method of the medical institutions issued in various cities, the medical insurance fund supervision platform (for example, third party platforms such as an intelligent auditing platform of a medical insurance bureau and a flight inspection system can output punishment data of the medical insurance fund supervision platform to each medical institution). The intelligent auditing system of the medical insurance bureau can find out the illegal event through the routine examination of the hospital; the flight inspection system can randomly inspect each medical institution irregularly and can also find illegal events.
When the credit event data collected in S101 is penalty data of the medical insurance fund supervision platform for each medical institution, S102 may be implemented by the following steps: and determining the index value of one or more preset monitoring indexes corresponding to each medical institution according to the penalty item data of each medical institution and the mapping relation between the pre-configured penalty item and the preset monitoring index.
Fig. 3 shows a procedure of quantization processing of the penalty term data. In the following, 3 specific penalty terms are listed, taking the penalty term of a certain city as an example, and the format is as follows:
carrying out specific punishment items in punishment events for a certain hospital: 30 ten thousand refused payment by medical security management department; the refused payment fee of the medical security administration is 20 ten thousand; the refused payment fee of the medical security administration is 10 ten thousand;
(vii) negative reporting penalty term: exposure to the media causes adverse effects;
third, the penalty item is checked not to be on duty during business.
The three cases exemplified above are penalty terms and have not been used for evaluation at each medical facility. The embodiment of the invention summarizes and can automatically convert the penalty item into the specific deduction value through a built-in algorithm. When the system receives penalty term data for a medical facility, the penalty term is matched to a particular index.
For example, when the penalty item of the withholding fee appears, the system can automatically match the indicator of the withholding fee, the scoring method of the indicator is graded, namely a certain gear interval corresponds to a score, for example, when the numerical interval of the indicator of the withholding fee is 20-30 ten thousand, 50 points are deducted; and when the numerical range of the 'charge refusal' index is 10-20 ten thousands, deducting 30 minutes, and when the numerical range of the 'charge refusal' index is 0-10 thousands, deducting 20 minutes.
Because the negative report deduction item is a one-time small probability event, the deduction item corresponds to a public opinion evaluation index, the index scoring method is direct scoring, adverse effects caused by media exposure are caused, and 30 points are deducted once.
If a certain medical institution is not checked out during business, the event is commonly present in the hospital, and a doctor may have a shift temporarily, so the index algorithm adopts a 'minimum value low-priority' algorithm. For example, 5 hospitals all have the deduction item, wherein hospital A appears 2 times, hospital B appears 3 times, hospital C appears 5 times, hospital D appears 7 times, and hospital F appears 10 times. In the embodiment of the present invention, when the evaluation score of each index is a deducted score, the lower the index value is, the better the index value is, in one embodiment, the lowest index value may be used as a reference value, for example, 1 point, the reference value proportion is 20%, and the other hospital scores are (the index value corresponding to the hospital index value/M point) x 100, where M point is a boundary value of 20%. When the M value in the example is 2, the deductive value of hospital B is: 3/2 × 1 ═ 1.5; hospital C has a deduction value of 5/2 × 1 ═ 2.5; by analogy, the deduction values of other hospitals can be obtained.
When the credit event data collected in S101 is questionnaire data of a questionnaire subject for each medical institution, S102 may be implemented by: and extracting index values of one or more preset monitoring indexes corresponding to each medical institution from the acquired questionnaire data. In a specific implementation, the step S101 may be implemented by: pushing questionnaire pages of all medical institutions to a user terminal of the questionnaire object; questionnaire data for each medical institution, which are filled in a questionnaire page by each questionnaire subject, are collected. Alternatively, the questionnaire can be delivered to each questionnaire object in the form of a short message.
As shown in fig. 4, the credit event platform sends a satisfaction survey questionnaire to the mobile phone of the patient, and the content of the satisfaction survey questionnaire is a question of the evaluation of the hospital credit. Meanwhile, the credit event platform can also send questionnaires to medical staff regularly to evaluate the credit related conditions of the hospital where the staff is located. In specific implementation, the credit event platform may use an average value of evaluation scores of a certain index in a plurality of questionnaires as an index score corresponding to the index.
S103, according to the index value of each preset monitoring index corresponding to each medical institution, determining the credit evaluation score of each preset monitoring index corresponding to each medical institution.
In one embodiment, the step S103 may be implemented by: acquiring a plurality of value interval ranges corresponding to each preset monitoring index, wherein each value interval range corresponds to a credit evaluation score; determining the numerical range of each medical institution corresponding to each preset monitoring index according to the index value of each medical institution corresponding to each preset monitoring index; and acquiring the credit evaluation score of each medical institution corresponding to each preset monitoring index according to the numerical range of each medical institution corresponding to each preset monitoring index.
And S104, determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, wherein the credit evaluation result is used for reflecting the risk degree of the medical institution illegal operation medical insurance fund.
It should be noted that after determining the credit assessment score of each preset monitoring index corresponding to each medical institution, the credit assessment score of each preset monitoring index corresponding to each medical institution may be weighted and averaged according to the preset weight value of each preset monitoring index, so as to obtain the credit assessment score reflecting the risk degree of the medical insurance fund for illegal operation of each medical institution, that is, the credit assessment result of each medical institution.
As can be seen from the above, in the online monitoring method for medical insurance fund illegal operation events provided in the embodiment of the present invention, the credit event data of each medical institution is collected, and the collected credit event data is subjected to index quantization processing, so as to obtain the index value of each preset monitoring index corresponding to each medical institution, further determine the credit evaluation score of each preset monitoring index corresponding to each medical institution according to the index value of each preset monitoring index corresponding to each medical institution, and finally determine the credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, so as to reflect the risk degree of illegal operation of the medical insurance fund by each medical institution.
According to the online monitoring method for the medical insurance fund illegal operation events, provided by the embodiment of the invention, the risk degree of the illegal operation medical insurance fund of each medical institution is quantitatively evaluated according to the credit event data of each medical institution, so that the online monitoring of the illegal operation medical insurance fund events can be realized.
In an embodiment, after the step S104 is executed, the online monitoring method for medical insurance fund violation operation events provided in the embodiment of the present invention may further include the following steps:
and generating a credit evaluation report of each medical institution according to the credit evaluation result of each medical institution.
In an embodiment, after the step S104 is executed, the online monitoring method for medical insurance fund violation operation events provided in the embodiment of the present invention may further include the following steps:
and performing credit ranking on each medical institution according to the credit evaluation result of each medical institution.
Fig. 5 is a schematic view of an online monitoring system for medical insurance fund violation operation events provided in an embodiment of the present invention, and as shown in fig. 5, the online monitoring system for medical insurance fund violation operation events provided in an embodiment of the present invention mainly includes the following two parts:
data access engine: credit event data for accessing an external system (e.g., medical data of each medical institution stored in a medical insurance bureau system, data of penalty items of a medical insurance supervision platform for each medical institution, and questionnaire data of an internet user side user (i.e., questionnaire object) for each medical institution) converts various credit event data into index data by using rule configuration, index mapping, aggregation calculation, a short message platform, and the like.
For medical data of the medical insurance bureau system, the data access engine can customize index screening rules, and government officers can make indexes needing to be screened in the current monitoring period through the engine. For example, three indexes of medical expense amplification, hospitalization expense amplification and outpatient expense amplification are monitored in the current monitoring period, the data access engine can capture credit event data in the current monitoring period in an asynchronous mode, and index values of the three preset monitoring indexes are calculated.
For the penalty item data issued by the medical insurance fund supervision platform to each medical institution, the data access engine associates the penalty item with the preset monitoring index so as to map the collected penalty item data into corresponding index data.
For the patients or medical staff at the internet user side, a part of users (for example, 20% of users) can be randomly selected to issue a questionnaire in a short message manner, and after the questionnaire is received, questionnaire data is converted into corresponding monitoring index data.
Second, index score calculation engine: the method is used for scoring the index value accessed by the data access engine according to the pre-configured index, scoring each preset monitoring index, and performing weighted average calculation on each preset monitoring index corresponding to each medical institution according to the weight value of each pre-configured preset monitoring index to obtain the evaluation score (the deduction value in the embodiment of the invention) of each medical institution.
In specific implementation, the index score calculation engine may issue the evaluation scores of each medical institution to each medical institution, and each medical institution confirms or complains the evaluation, and the final evaluation is completed after the complains are unsuccessful or confirmed.
Fig. 6 is a flowchart of a specific implementation of online monitoring of a medical insurance fund to an illegal operation event based on medical insurance bureau settlement data according to an embodiment of the present invention, and as shown in fig. 6, the flowchart mainly includes:
and (I) making an index extraction formula and an index scoring method which need to be monitored by an operator on a credit supervision platform. For example, three examination indexes are defined as "increase in medical cost (current medical cost-current medical cost)/current medical cost", "increase in total cost of hospital (current medical cost-current medical cost)/current medical cost", "increase in total cost of clinic (current clinic cost-current clinic cost)/current clinic cost", and a scoring method is set. The system can perform data extraction and index value calculation according to indexes set by the operator.
And (II) respectively judging and deducting according to the index values in the grading process, and if the index values exceed a preset threshold value, determining that the index values of the abnormal events exist, and ending the process if the abnormal events do not exist. And the mark deduction calculation is carried out according to the marking method when the abnormal event index exists.
And (III) the primary result of the deduction is notified to each illegal medical institution, and each medical institution is notified to confirm that the deduction is correct or deducts credit finally after overdue and unprocessed. If the deduction is objectified, the subsidiary materials can be submitted, and after the subsidiary materials are audited by an office worker, the subsidiary materials are determined not to have problems and are not processed by deduction.
And (IV) after the deduction processing is finished, the deduction engine can count the medical institutions with the deducted points to report the list of the protocols to be relieved.
When the medical insurance fund and the illegal operation event are monitored on line based on the settlement data of the medical insurance bureau, the received penalty item and the index can be mapped, and then the step of converting the original data into the index value in the figure 6 is carried out, and the following process is as shown in the figure 6.
When the medical insurance fund to violation operation event is monitored online based on the questionnaire object and the questionnaire data of each medical institution, the received questionnaire score and the index can be mapped, and then the step of converting the original data into the index value in fig. 6 is performed, and the subsequent flow is as shown in fig. 6.
The on-line monitoring scheme of the medical insurance fund illegal operation event provided by the embodiment of the invention is a closed-loop scheme based on illegal operation event discovery, index quantification, index value mapping and credit evaluation, can provide multiple access modes of credit event data (the illegal event can be detected by medical data such as settlement detail, inspection and check and the like, the illegal event can be adapted to the illegal event discovered by a third-party inspection system, the evaluation content of a patient to a medical institution after the patient visits a doctor can also be adapted), the butted credit event data are automatically converted into index values, the risk degree of illegal operation of the medical insurance fund of each medical institution is quantitatively evaluated, then the quantitative evaluation result of each medical institution is utilized to carry out credit sharing ranking on each hospital, the credit result of each hospital is ranked to the medical insurance bureau, the patient in a doctor's visit, the business insurance company or a third-party internet platform, the medical insurance bureau can use the shared credit ranking data to carry out penalty score deduction on the hospital, and the scoring engine pushes a protocol suspension list to the gold insurance core system; so that the hospitalized patients can make hospital and physician selections using the credit ranking data; enabling the underwriting company to utilize the credit ranking data for health insurance partner selection; the third-party internet platform can use the credit ranking data as value-added services, for example, public comment increases the relevant information of medical institutions, and the relevant platform is blank at present.
Based on the same inventive concept, the embodiment of the invention also provides an online monitoring device for medical insurance fund illegal operation events, which is described in the following embodiment. Because the principle of solving the problems of the device is similar to the online monitoring method of the medical insurance fund illegal operation event, the implementation of the device can refer to the implementation of the online monitoring method of the medical insurance fund illegal operation event, and repeated parts are not described again.
Fig. 7 is a schematic view of an online monitoring device for medical insurance fund violation operation events provided in an embodiment of the present invention, and as shown in fig. 7, the device includes: a data collection module 71, an index quantification module 72, an index evaluation module 73, and a credit evaluation module 74.
The data acquisition module 71 is configured to acquire credit event data of each medical institution, where the credit event data is used to reflect whether the medical institution violates an operation insurance fund; the index quantization module 72 is configured to perform index quantization processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution; the index evaluation module 73 is used for determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each medical institution corresponding to each preset monitoring index; and the credit evaluation module 74 is used for determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, wherein the credit evaluation result is used for reflecting the risk degree of illegal operation of the medical insurance fund of the medical institution.
As can be seen from the above, the online monitoring device for medical insurance fund violation operation events provided in the embodiment of the present invention collects credit event data of each medical institution through the data collection module 71; index quantization processing is carried out on the collected credit event data through an index quantization module 72 to obtain an index value of each preset monitoring index corresponding to each medical institution; determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each preset monitoring index corresponding to each medical institution through the index evaluation module 73; and determining a credit evaluation result of each medical institution through the credit evaluation module 74 according to the credit evaluation score of each preset monitoring index corresponding to each medical institution so as to reflect the risk degree of illegal operation of the medical insurance fund of each medical institution.
According to the online monitoring device for the medical insurance fund illegal operation events, provided by the embodiment of the invention, the risk degree of the illegal operation medical insurance fund of each medical institution is quantitatively evaluated according to the credit event data of each medical institution, so that the online monitoring of the illegal operation medical insurance fund events can be realized.
In one embodiment, the data acquisition module 71 is used for acquiring medical data of each medical institution; the index quantization module 72 is configured to perform index quantization processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution, and includes: loading medical data of each medical institution stored in a medical insurance bureau system database into an Elasticissearch engine by adopting a Logstash tool; and performing aggregation processing on the medical data from each medical institution based on an Elasticissearch engine to obtain credit event data of each medical institution.
In one embodiment, the data collection module 71 is configured to collect data of penalty items of the medical insurance fund supervision platform for each medical institution; the index quantization module 72 is configured to perform index quantization processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution, and includes: and determining the index value of one or more preset monitoring indexes corresponding to each medical institution according to the penalty item data of each medical institution and the mapping relation between the pre-configured penalty item and the preset monitoring index.
In one embodiment, the data collection module 71 is configured to collect credit event data of each medical institution, and includes: pushing questionnaire pages of all medical institutions to a user terminal of the questionnaire object; collecting questionnaire data which are filled in a questionnaire page by each questionnaire object and are applied to each medical institution; the index quantization module 72 is configured to perform index quantization processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution, and includes: and extracting index values of one or more preset monitoring indexes corresponding to each medical institution from the acquired questionnaire data.
In one embodiment, the index evaluation module 73 is configured to: acquiring a plurality of value interval ranges corresponding to each preset monitoring index, wherein each value interval range corresponds to a credit evaluation score; determining the numerical range of each medical institution corresponding to each preset monitoring index according to the index value of each medical institution corresponding to each preset monitoring index; and acquiring the credit evaluation score of each medical institution corresponding to each preset monitoring index according to the numerical range of each medical institution corresponding to each preset monitoring index.
In one embodiment, the online monitoring apparatus for medical insurance fund violation operation events provided in the embodiment of the present invention may further include: and a report generation module 75, configured to generate a credit evaluation report for each medical institution according to the credit evaluation result of each medical institution.
In one embodiment, the online monitoring apparatus for medical insurance fund violation operation events provided in the embodiment of the present invention may further include: and a credit ranking module 76 for ranking the credit of each medical institution according to the credit evaluation result of each medical institution.
Based on the same inventive concept, the embodiment of the invention also provides a computer device, which is used for solving the technical problem that the existing medical insurance fund management system cannot monitor the illegal operation events of the medical insurance fund on line.
Based on the same inventive concept, the embodiment of the invention also provides a computer readable storage medium, which is used for solving the technical problem that the existing medical insurance fund management system cannot monitor the illegal operation events of the medical insurance fund on line.
In summary, embodiments of the present invention provide an online monitoring method, an online monitoring device, a computer device, and a computer-readable storage medium for a medical insurance fund violation operation event, in which credit event data of each medical institution is collected, and the collected credit event data is subjected to index quantization to obtain an index value of each medical institution corresponding to each preset monitoring index, and further, a credit evaluation score of each medical institution corresponding to each preset monitoring index is determined according to the index value of each medical institution corresponding to each preset monitoring index, and finally, a credit evaluation result of each medical institution is determined according to the credit evaluation score of each medical institution corresponding to each preset monitoring index, so as to reflect a risk degree of each medical institution violating the operation of the medical insurance fund.
According to the embodiment of the invention, the risk degree of illegal operation of the medical insurance fund of each medical institution is quantitatively evaluated according to the credit event data of each medical institution, so that the illegal operation event of the medical insurance fund can be monitored on line.
As will be appreciated by one skilled in the art, embodiments of the present invention may be provided as a method, system, or computer program product. Accordingly, the present invention may take the form of an entirely hardware embodiment, an entirely software embodiment or an embodiment combining software and hardware aspects. Furthermore, the present invention may take the form of a computer program product embodied on one or more computer-usable storage media (including, but not limited to, disk storage, CD-ROM, optical storage, and the like) having computer-usable program code embodied therein.
The present invention is described with reference to flowchart illustrations and/or block diagrams of methods, apparatus (systems), and computer program products according to embodiments of the invention. It will be understood that each flow and/or block of the flow diagrams and/or block diagrams, and combinations of flows and/or blocks in the flow diagrams and/or block diagrams, can be implemented by computer program instructions. These computer program instructions may be provided to a processor of a general purpose computer, special purpose computer, embedded processor, or other programmable data processing apparatus to produce a machine, such that the instructions, which execute via the processor of the computer or other programmable data processing apparatus, create means for implementing the functions specified in the flowchart flow or flows and/or block diagram block or blocks.
These computer program instructions may also be stored in a computer-readable memory that can direct a computer or other programmable data processing apparatus to function in a particular manner, such that the instructions stored in the computer-readable memory produce an article of manufacture including instruction means which implement the function specified in the flowchart flow or flows and/or block diagram block or blocks.
These computer program instructions may also be loaded onto a computer or other programmable data processing apparatus to cause a series of operational steps to be performed on the computer or other programmable apparatus to produce a computer implemented process such that the instructions which execute on the computer or other programmable apparatus provide steps for implementing the functions specified in the flowchart flow or flows and/or block diagram block or blocks.
The above-mentioned embodiments are intended to illustrate the objects, technical solutions and advantages of the present invention in further detail, and it should be understood that the above-mentioned embodiments are only exemplary embodiments of the present invention, and are not intended to limit the scope of the present invention, and any modifications, equivalent substitutions, improvements and the like made within the spirit and principle of the present invention should be included in the scope of the present invention.
Claims (10)
1. An online monitoring method for medical insurance fund violation operation events is characterized by comprising the following steps:
collecting credit event data of each medical institution, wherein the credit event data is used for reflecting whether the medical institution violates operation of a medical insurance fund;
performing index quantification processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution;
determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each medical institution corresponding to each preset monitoring index;
and determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, wherein the credit evaluation result is used for reflecting the risk degree of the medical institution for illegal operation of the medical insurance fund.
2. The method of claim 1,
collecting credit event data for each medical institution, comprising: acquiring medical data of each medical institution;
the method for carrying out index quantification processing on the credit event data of each medical institution to obtain the index value of one or more preset monitoring indexes corresponding to each medical institution comprises the following steps: loading medical data of each medical institution stored in a medical insurance bureau system database into an Elasticissearch engine by adopting a Logstash tool; and performing aggregation processing on the medical data from each medical institution based on an Elasticissearch engine to obtain credit event data of each medical institution.
3. The method of claim 1,
collecting credit event data for each medical institution, comprising: collecting punishment data of the medical insurance fund supervision platform on each medical institution;
the method for carrying out index quantification processing on the credit event data of each medical institution to obtain the index value of one or more preset monitoring indexes corresponding to each medical institution comprises the following steps: and determining the index value of one or more preset monitoring indexes corresponding to each medical institution according to the penalty item data of each medical institution and the mapping relation between the pre-configured penalty item and the preset monitoring index.
4. The method of claim 1,
collecting credit event data for each medical institution, comprising: pushing questionnaire pages of all medical institutions to a user terminal of the questionnaire object; collecting questionnaire data which are filled in a questionnaire page by each questionnaire object and are applied to each medical institution;
the method for carrying out index quantification processing on the credit event data of each medical institution to obtain the index value of one or more preset monitoring indexes corresponding to each medical institution comprises the following steps: and extracting index values of one or more preset monitoring indexes corresponding to each medical institution from the acquired questionnaire data.
5. The method of claim 1, wherein determining the credit assessment score for each medical institution for each of the predetermined monitoring metrics based on the metric value for each medical institution for each of the predetermined monitoring metrics comprises:
acquiring a plurality of value interval ranges corresponding to each preset monitoring index, wherein each value interval range corresponds to a credit evaluation score;
determining the numerical range of each medical institution corresponding to each preset monitoring index according to the index value of each medical institution corresponding to each preset monitoring index;
and acquiring the credit evaluation score of each medical institution corresponding to each preset monitoring index according to the numerical range of each medical institution corresponding to each preset monitoring index.
6. The method of any one of claims 1 to 5, wherein after determining the credit assessment result for each medical institution based on the credit assessment score for each medical institution for the respective predetermined monitoring metric, the method further comprises:
and generating a credit evaluation report of each medical institution according to the credit evaluation result of each medical institution.
7. The method of any one of claims 1 to 5, wherein after determining the credit assessment result for each medical institution based on the credit assessment score for each medical institution for the respective predetermined monitoring metric, the method further comprises:
and performing credit ranking on each medical institution according to the credit evaluation result of each medical institution.
8. An on-line monitoring device for medical insurance fund violation operation events, which is characterized by comprising:
the system comprises a data acquisition module, a credit event processing module and a credit event processing module, wherein the data acquisition module is used for acquiring credit event data of each medical institution, and the credit event data is used for reflecting whether the medical institution violates operation of a medical insurance fund;
the index quantization module is used for performing index quantization processing on the credit event data of each medical institution to obtain an index value of one or more preset monitoring indexes corresponding to each medical institution;
the index evaluation module is used for determining credit evaluation scores of each medical institution corresponding to each preset monitoring index according to the index values of each medical institution corresponding to each preset monitoring index;
and the credit evaluation module is used for determining a credit evaluation result of each medical institution according to the credit evaluation score of each preset monitoring index corresponding to each medical institution, and the credit evaluation result is used for reflecting the risk degree of illegal operation of the medical insurance fund of the medical institution.
9. A computer device comprising a memory, a processor and a computer program stored on the memory and executable on the processor, wherein the processor implements a method for online monitoring of medical insurance fund violation events according to any one of claims 1 to 7 when executing the computer program.
10. A computer-readable storage medium storing a computer program for executing the method for online monitoring of medical insurance fund violation operation events according to any one of claims 1 to 7.
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