CN113706321A - Medical insurance risk auditing method and device, computer equipment and readable storage medium - Google Patents
Medical insurance risk auditing method and device, computer equipment and readable storage medium Download PDFInfo
- Publication number
- CN113706321A CN113706321A CN202111012440.5A CN202111012440A CN113706321A CN 113706321 A CN113706321 A CN 113706321A CN 202111012440 A CN202111012440 A CN 202111012440A CN 113706321 A CN113706321 A CN 113706321A
- Authority
- CN
- China
- Prior art keywords
- medical insurance
- preset
- rule
- case
- audit
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
- Pending
Links
- 238000000034 method Methods 0.000 title claims abstract description 87
- 238000012550 audit Methods 0.000 claims abstract description 157
- 238000003745 diagnosis Methods 0.000 claims abstract description 104
- 235000010627 Phaseolus vulgaris Nutrition 0.000 claims description 33
- 244000046052 Phaseolus vulgaris Species 0.000 claims description 33
- 238000012545 processing Methods 0.000 claims description 24
- 238000012795 verification Methods 0.000 claims description 23
- 238000004590 computer program Methods 0.000 claims description 18
- 230000002159 abnormal effect Effects 0.000 claims description 12
- 201000010099 disease Diseases 0.000 abstract description 19
- 208000037265 diseases, disorders, signs and symptoms Diseases 0.000 abstract description 19
- 238000005516 engineering process Methods 0.000 description 15
- 238000010586 diagram Methods 0.000 description 11
- 238000013473 artificial intelligence Methods 0.000 description 9
- 230000006870 function Effects 0.000 description 6
- 230000008569 process Effects 0.000 description 6
- 238000004891 communication Methods 0.000 description 3
- 238000012986 modification Methods 0.000 description 3
- 230000004048 modification Effects 0.000 description 3
- 210000001503 joint Anatomy 0.000 description 2
- 238000007726 management method Methods 0.000 description 2
- 238000006467 substitution reaction Methods 0.000 description 2
- 238000007792 addition Methods 0.000 description 1
- 238000003491 array Methods 0.000 description 1
- 230000008878 coupling Effects 0.000 description 1
- 238000010168 coupling process Methods 0.000 description 1
- 238000005859 coupling reaction Methods 0.000 description 1
- 125000004122 cyclic group Chemical group 0.000 description 1
- 238000013135 deep learning Methods 0.000 description 1
- 238000012217 deletion Methods 0.000 description 1
- 230000037430 deletion Effects 0.000 description 1
- 238000013461 design Methods 0.000 description 1
- 238000011161 development Methods 0.000 description 1
- 230000036541 health Effects 0.000 description 1
- 230000003993 interaction Effects 0.000 description 1
- 238000010801 machine learning Methods 0.000 description 1
- 238000012423 maintenance Methods 0.000 description 1
- 238000013507 mapping Methods 0.000 description 1
- 238000003032 molecular docking Methods 0.000 description 1
- 238000003058 natural language processing Methods 0.000 description 1
- 230000003287 optical effect Effects 0.000 description 1
- 230000008520 organization Effects 0.000 description 1
- 238000012954 risk control Methods 0.000 description 1
- 230000008719 thickening Effects 0.000 description 1
- 238000012384 transportation and delivery Methods 0.000 description 1
- 230000001960 triggered effect Effects 0.000 description 1
Images
Classifications
-
- 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
-
- 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
- G06Q10/00—Administration; Management
- G06Q10/10—Office automation; Time management
- G06Q10/103—Workflow collaboration or project management
Landscapes
- Business, Economics & Management (AREA)
- Engineering & Computer Science (AREA)
- Strategic Management (AREA)
- Human Resources & Organizations (AREA)
- General Business, Economics & Management (AREA)
- Accounting & Taxation (AREA)
- Marketing (AREA)
- Entrepreneurship & Innovation (AREA)
- Economics (AREA)
- Physics & Mathematics (AREA)
- Finance (AREA)
- General Physics & Mathematics (AREA)
- Theoretical Computer Science (AREA)
- Technology Law (AREA)
- Data Mining & Analysis (AREA)
- Development Economics (AREA)
- Operations Research (AREA)
- Quality & Reliability (AREA)
- Tourism & Hospitality (AREA)
- Medical Treatment And Welfare Office Work (AREA)
- Financial Or Insurance-Related Operations Such As Payment And Settlement (AREA)
Abstract
The application belongs to the technical field of medical data, and provides a medical insurance risk auditing method and device, computer equipment and a computer readable storage medium. According to the method and the device, the medical insurance case is obtained, the medical insurance case comprises medical insurance case identification and medical insurance case diagnosis and treatment information, the preset medical insurance audit rule list corresponding to the medical insurance case is obtained according to the medical insurance case identification, the preset medical insurance audit rule list comprises the preset medical insurance audit rule ID, the preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID is obtained according to the preset medical insurance audit rule ID, the preset medical insurance check rule set comprises the preset medical insurance check rule, the medical insurance case diagnosis and treatment information is audited, a large amount of audit data corresponding to major disease medical insurance in each area can be correspondingly set and verified, the auditing efficiency of the major disease medical insurance can be improved, and further the risk early warning efficiency of the major disease medical insurance is improved.
Description
Technical Field
The application relates to the technical field of artificial intelligence, in particular to the technical field of medical data, and specifically relates to a medical insurance risk auditing method and device, computer equipment and a computer-readable storage medium.
Background
In the medical insurance for major illness, when a patient is used as an applicant and carries out medical insurance claim settlement, the risk examination of the medical insurance is more cautious because the claim settlement amount related to the medical insurance for major illness is larger. When medical insurance risk is checked, a large amount of doctor-patient data such as a hospital for visiting a doctor, disease information, treatment information and the like of the applicant can be involved. Due to the particularity of the major illness medical insurance, fee deduction rules related to the major illness medical insurance are more complex, and fee deduction rules in different regions are also different, so that the data volume related to the major illness insurance is larger, the traditional insurance early warning auditing function cannot be completely suitable for the major illness insurance, the major illness insurance is audited by adopting the traditional early warning auditing function, errors are easy to occur due to the large data volume, and the risk early warning efficiency of the major illness insurance is reduced.
Disclosure of Invention
The application provides a medical insurance risk auditing method and device, computer equipment and a computer readable storage medium, which can solve the technical problem that the traditional technology has low risk early warning efficiency on major disease insurance.
In a first aspect, the present application provides a medical insurance risk auditing method, including: acquiring a medical insurance case, wherein the medical insurance case comprises medical insurance case identification and medical insurance case diagnosis and treatment information; acquiring a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identification, wherein the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID; acquiring a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID according to the preset medical insurance audit rule ID; and auditing the medical insurance case diagnosis and treatment information by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set.
In a second aspect, the present application further provides a medical insurance risk auditing device, including: the medical insurance case identification and diagnosis and treatment system comprises a first acquisition unit and a second acquisition unit, wherein the first acquisition unit is used for acquiring a medical insurance case which comprises medical insurance case identification and medical insurance case diagnosis and treatment information; the second obtaining unit is used for obtaining a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identification, wherein the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID; a third obtaining unit, configured to obtain, according to the preset medical insurance audit rule ID, a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID; and the auditing unit is used for auditing the medical insurance case diagnosis and treatment information by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set. .
In a third aspect, the present application further provides a computer device, which includes a memory and a processor, where the memory stores a computer program, and the processor implements the steps of the medical insurance risk auditing method when executing the computer program.
In a fourth aspect, the present application further provides a computer-readable storage medium, in which a computer program is stored, which, when executed by a processor, causes the processor to perform the steps of the medical insurance risk auditing method.
The application provides a medical insurance risk auditing method and device, computer equipment and a computer readable storage medium. According to the method and the device, through acquiring the medical insurance case, the medical insurance case comprises medical insurance case identification and medical insurance case diagnosis and treatment information, the preset medical insurance audit rule list corresponding to the medical insurance case is acquired according to the medical insurance case identification, the preset medical insurance audit rule list comprises the preset medical insurance audit rule ID, the preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID is acquired according to the preset medical insurance audit rule ID, the preset medical insurance check rule set comprising the preset medical insurance check rule set is adopted to audit the medical insurance case diagnosis and treatment information, and the corresponding setting and checking can be carried out on a large amount of audit data corresponding to the major illness medical insurance in each area, so that the auditing efficiency of the major illness medical insurance can be improved, and further the risk early warning efficiency of the major illness medical insurance is improved.
Drawings
In order to more clearly illustrate the technical solutions of the embodiments of the present application, the drawings needed to be used in the description of the embodiments are briefly introduced below, and it is obvious that the drawings in the following description are some embodiments of the present application, and it is obvious for those skilled in the art to obtain other drawings based on these drawings without creative efforts.
Fig. 1 is a schematic flowchart of a medical insurance risk auditing method provided in an embodiment of the present application;
fig. 2 is a schematic chain diagram of medical insurance audit rules in the medical insurance risk audit method provided in the embodiment of the present application;
fig. 3 is a schematic view of a first sub-flow of a medical insurance risk auditing method according to an embodiment of the present application;
fig. 4 is a second sub-flow diagram of a medical insurance risk auditing method according to an embodiment of the present application;
fig. 5 is a schematic view of a third sub-flow of a medical insurance risk auditing method according to an embodiment of the present application;
fig. 6 is a fourth sub-flow diagram of the medical insurance risk auditing method according to the embodiment of the present application;
fig. 7 is a schematic block diagram of a medical insurance risk auditing apparatus provided in an embodiment of the present application;
fig. 8 is a schematic block diagram of a computer device provided in an embodiment of the present application.
Detailed Description
The technical solutions in the embodiments of the present application will be clearly and completely described below with reference to the drawings in the embodiments of the present application, and it is obvious that the described embodiments are some, but not all, embodiments of the present application. All other embodiments, which can be derived by a person skilled in the art from the embodiments given herein without making any creative effort, shall fall within the protection scope of the present application.
It will be understood that the terms "comprises" and/or "comprising," when used in this specification and the appended claims, specify the presence of stated features, integers, steps, operations, elements, and/or components, but do not preclude the presence or addition of one or more other features, integers, steps, operations, elements, components, and/or groups thereof.
Referring to fig. 1 and fig. 2, fig. 1 is a schematic flow chart of a medical insurance risk auditing method provided in the embodiment of the present application, and fig. 2 is a schematic chain of medical insurance auditing rules in the medical insurance risk auditing method provided in the embodiment of the present application. As shown in fig. 1, the medical insurance risk auditing method may be applied to a server for performing medical insurance risk auditing, where the server may be an independent server, or a cloud server that provides basic cloud computing services such as cloud service, a cloud database, cloud computing, a cloud function, cloud storage, web service, cloud communication, middleware service, domain name service, security service, a Content Delivery Network (CDN), and a big data and artificial intelligence platform, and the method includes the following steps S11 to S14:
s11, acquiring a medical insurance case, wherein the medical insurance case comprises a medical insurance case identification and medical information of the medical insurance case.
Specifically, when a patient is used as an applicant and carries out medical treatment claim for major illness, doctor-patient data corresponding to doctor-patient information is uploaded to a platform for medical insurance risk auditing in the form of medical insurance cases, and risk control auditing is carried out, wherein the doctor-patient data comprises regions, hospitals, doctors, departments, diseases, relevant treatment information and the like for treatment. The medical data may be acquired and processed based on an Artificial Intelligence (AI) technology, wherein the AI (Artificial Intelligence) is a theory, method, technology and application system that simulates, extends and expands human Intelligence, senses the environment, acquires knowledge and uses the knowledge to obtain the best result by using a digital computer or a machine controlled by a digital computer, the AI (Artificial Intelligence) basic technology generally includes technologies such as sensors, dedicated intelligent chips, cloud computing, distributed storage, big data processing technology, operation/interaction system, mechatronics, etc., and the AI (Artificial Intelligence) software technology mainly includes computer vision technology, robot technology, biological recognition technology, voice processing technology, natural language processing technology, machine learning/deep learning, etc. For example, the Medical data may be calculated and stored based on a block chain and cloud computing, and further, the Medical data may be transmitted, calculated and stored through a Medical cloud, where the Medical cloud (Medical cloud) refers to a Medical technology based on new technologies such as cloud computing, mobile technology, multimedia, 4G communication, big data, and the internet of things, and is used to create a Medical health service cloud platform by using "cloud computing" in combination with the Medical technology, so that sharing of Medical resources and expansion of Medical scope are realized. Like the appointment register, the electronic medical record, the medical insurance and the like of the existing hospital are all products combining cloud computing and the medical field, and the medical cloud also has the advantages of data security, information sharing, dynamic expansion and overall layout.
The method comprises the steps of receiving medical insurance cases sent by each preset medical insurance case channel, writing all the medical insurance cases into a preset case task processing table, and obtaining the medical insurance cases from the preset case task processing table when the medical insurance cases are checked, wherein the medical insurance cases generally comprise medical insurance case identification of the medical insurance cases and specific contents of cases corresponding to medical information of the medical insurance cases.
Further, please refer to fig. 3, fig. 3 is a schematic view of a first sub-flow of a medical insurance risk auditing method provided in an embodiment of the present application, and as shown in fig. 3, in this embodiment, the acquiring a medical insurance case includes:
s111, receiving medical insurance cases uploaded by a plurality of preset medical insurance case data sources;
s112, writing the medical insurance case into a preset asynchronous case task processing table;
s113, polling the preset asynchronous case task processing table, and acquiring the medical insurance case from the preset asynchronous case task processing table.
Specifically, a medical insurance service for major diseases generally has a plurality of medical insurance case data sources, and auditing medical insurance cases is processed by the same background, and when the background processes medical insurance cases of the plurality of medical insurance case data sources, the medical insurance cases uploaded by a plurality of preset medical insurance case data sources can be received and written into a preset asynchronous case task processing table, so as to process asynchronous tasks on the medical insurance cases, and then the preset asynchronous case task processing table is polled through asynchronous tasks, so that the medical insurance cases are obtained from the preset asynchronous case task processing table, and the efficiency and the auditing quality of auditing risks of major disease insurance are ensured under the condition that the data volume of major disease insurance is huge.
S12, acquiring a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identification, wherein the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID.
Specifically, the corresponding preset medical insurance audit rules are preset according to the medical insurance attributes of major medical insurance such as institutions and projects related to major medical insurance, because the major medical insurance relates to more audit rules, a form of a preset medical insurance audit rule list can be adopted to describe a plurality of audit rules related to major medical insurance, the preset medical insurance audit rule list comprises a plurality of preset medical insurance audit rule IDs, each preset medical insurance audit rule ID is associated with a preset medical insurance check rule set, each preset medical insurance check rule set comprises a plurality of specific check rules, the preset medical insurance audit rule list can comprise necessary check rules and configurable check rules, the necessary check rules can comprise blacklist check and butt joint original data negative number check, particularly for major medical insurance, negative number check is carried out on butt joint original settlement data based on a basic medical insurance system, namely, whether a negative value exists in the docking data of the current medical insurance case diagnosis and treatment information is judged, if the negative value exists in the medical insurance case diagnosis and treatment information which does not allow the negative value, the medical insurance case diagnosis and treatment information is judged to be abnormal directly, the data accuracy can be ensured, the configurable check rule can comprise the diagnosis and treatment information check, the medical details check, the hospital entrance and exit diagnosis check and the like, the necessary check rule and the configurable check rule can be edited through respective corresponding preset management menus, as shown in fig. 2, the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID1, a preset medical insurance audit rule ID2 and a preset medical insurance audit rule ID3, the preset medical insurance audit rule ID1 is associated with a preset medical insurance check rule set 1, the preset medical insurance check rule set 1 comprises a preset medical insurance check rule 11, a preset medical insurance check rule 12 and a preset medical insurance check rule 13, the total number of the three verification rules is three, and the rest of the verification rules in fig. 2 are analogized in sequence, and the medical insurance audit rule can be a medical bill audit rule, a medical detail audit rule or a diagnosis audit rule, so that a plurality of verification rules of medical insurance for major diseases are classified according to rule attributes of the verification rules through a hierarchical preset medical insurance audit rule list, and the plurality of verification rules are audited, and thus, corresponding preset medical insurance audit rule lists can be respectively set for different regions, different institutions and different items, so that personalized configuration of medical insurance audit is realized, and pertinence, accuracy and audit efficiency of medical insurance audit are improved. For example, a corresponding preset medical insurance audit rule list is set for a medical item, so that the preset medical insurance audit rule list corresponding to a medical insurance case can be determined according to the medical item to which the medical insurance case belongs, and a medical insurance case identifier of the medical insurance case is associated with a preset table identifier of the preset medical insurance audit rule list, so as to be able to associate the corresponding preset medical insurance audit rule list according to the medical insurance case identifier, wherein the preset medical insurance case identifier can be a case number of the medical insurance case, the preset table identifier can be a table identifier such as a preset table ID and a preset table name, and then the preset medical insurance rule list associated with the preset medical insurance case identifier is identified according to specific contents contained in the preset medical insurance case identifier, for example, the preset medical insurance audit rule list associated with the preset medical insurance case identifier can be identified according to a code setting contained in the preset medical insurance case identifier, the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID, wherein the ID is an Identitydocument and is an identification number, an account number, a unique code and the like of the preset medical insurance audit rule.
Further, referring to fig. 2 and fig. 4, fig. 4 is a second sub-flow schematic diagram of the medical insurance risk auditing method according to the embodiment of the present application, as shown in fig. 4, in this embodiment, the obtaining a preset medical insurance auditing rule list corresponding to the medical insurance case according to the medical insurance case identifier includes:
s121, determining a preset medical insurance location to which the medical insurance case belongs according to the medical insurance case identification;
s122, determining a preset medical insurance project to which the medical insurance case belongs according to the place to which the preset medical insurance belongs;
s123, acquiring a preset medical insurance audit rule list corresponding to the preset medical insurance project according to the preset medical insurance project to obtain a preset medical insurance audit rule list corresponding to the medical insurance case.
Specifically, for a situation that medical insurance audit rules of medical insurance of a major illness in each medical insurance project of each region may be different, a corresponding preset medical insurance audit rule list may be set in advance for each medical insurance project of each region.
After the medical insurance case identification of the medical insurance case is obtained, determining the preset medical insurance place of the medical insurance case according to the medical insurance case identification, determining the preset medical insurance project of the medical insurance case according to the preset medical insurance place, then obtaining the preset medical insurance audit rule list corresponding to the preset medical insurance project according to the preset medical insurance project, further obtaining the preset medical insurance audit rule list corresponding to the medical insurance case, and then auditing the medical insurance case by adopting the preset medical insurance audit rule list, so that the individual configuration and the fine configuration of the medical insurance of the major illness can be realized by adopting the corresponding risk audit rule according to each medical insurance area and each medical insurance project and even further combining each medical insurance organization to adopt the corresponding medical insurance risk audit rule, the accuracy of medical insurance risks of the major illness is checked, and the quality and efficiency of checking the medical insurance risks of each medical insurance area and each medical insurance project are improved.
And S13, acquiring a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID according to the preset medical insurance audit rule ID.
Specifically, the corresponding preset medical insurance audit rule ID and the preset medical insurance audit rule can be prestored in advance according to a key value pair mode, for example, pre-storing the preset medical insurance audit rule ID and the preset medical insurance audit rule into a preset Map set according to a key value pair mode, the preset Map set is used for storing data with a mapping relation, two groups of values are stored in the Map set, one group of values is used for storing Key of the Map, the Key can be used for storing a preset medical insurance audit rule ID, the other group of values is used for storing Vlue of the Map, the Value can be used for storing a preset medical insurance check rule set, the Key and the corresponding Value form a Key-Value pair, therefore, a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID can be obtained according to the preset medical insurance audit rule ID, and the table structure of the same preset medical insurance audit rule list can store different types of check rules, so that the efficiency of setting the check rules is improved. Referring to fig. 2, as shown in fig. 2, each preset medical insurance audit rule ID is associated with a corresponding preset medical insurance check rule set, each preset medical insurance check rule set includes a plurality of specific check rules, for example, the preset medical insurance check rule set 1 corresponding to the preset medical insurance check rule ID1 included in the preset medical insurance check rule list may be a blacklist check set, the blacklist checking set is configured with blacklist contents such as a blacklist hospital, a department, a doctor, a paramedic and the like, and when the claim information of the medical insurance case relates to the contents such as the hospital, the department, the doctor, the paramedic and the like, a blacklist checking rule is triggered, the blacklist check set can edit the blacklist such as addition, deletion, modification and the like of the blacklist through a preset blacklist management menu, the efficiency of setting the blacklist check rule can be improved, and the accuracy and the efficiency of medical insurance risk auditing are further improved.
Therefore, after the preset medical insurance audit rule list corresponding to the medical insurance case is obtained according to the medical insurance case identifier, the preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID can be obtained according to the preset medical insurance audit rule ID included in the preset medical insurance audit rule list.
And S14, auditing the medical insurance case diagnosis and treatment information by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set.
Specifically, after the preset medical insurance check rule set is obtained, the medical insurance case diagnosis and treatment information can be checked by adopting the preset medical insurance check rules contained in the preset medical insurance check rule set, so that the medical insurance cases can be audited by using the preset medical insurance check rules, and the check rules in the preset medical insurance check rule set can be described in a mode of a preset medical insurance rule check method.
Further, referring to fig. 5, fig. 5 is a third sub-flow schematic diagram of the medical insurance risk auditing method provided in the embodiment of the present application, as shown in fig. 5, in this embodiment, the auditing the medical information of the medical insurance case by using the preset medical insurance check rule included in the preset medical insurance check rule set includes:
s141, initializing a realization class set based on a preset medical insurance rule corresponding to the preset medical insurance check rule set, calling a preset medical insurance rule initialization realization class contained in the preset medical insurance rule initialization realization class set, and checking medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule check method by adopting a preset medical insurance rule check method corresponding to the preset medical insurance rule initialization realization class;
and S142, circulating all the preset medical insurance rule checking methods contained in the preset medical insurance rule initialization realization class set, and checking all the medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule initialization realization class set.
Specifically, aiming at the situations that medical insurance deduction rules in different areas in medical insurance for major diseases are different and the medical insurance deduction rules for the medical insurance for the major diseases are large in quantity, in order to reduce the coupling degree between program modules for realizing medical insurance auditing and improve the convenience and efficiency of development and maintenance of medical insurance auditing projects, the medical insurance auditing efficiency is continuously improved, and the medical insurance check rules can be checked based on a preset medical insurance rule check interface mode. When the medical insurance case diagnosis and treatment information is verified by using a preset medical insurance verification rule, a unified preset medical insurance rule verification interface is defined, the preset medical insurance rule verification interface is used for defining a standard and a mark for verifying the medical insurance verification rule, a preset medical insurance rule implementation class of the preset medical insurance rule verification interface is used for verifying the specific preset medical insurance rule, and the preset medical insurance rule implementation class can be instantiated and realized based on a preset medical insurance rule abstract class, so that the preset medical insurance rule verification interface can directly call the preset medical insurance rule implementation class for verifying the specific medical insurance rule. When the medical insurance case diagnosis and treatment information is checked by adopting the preset medical insurance check rules contained in the preset medical insurance check rule set, acquiring the preset medical insurance rule initialization realization class set corresponding to the preset medical insurance check rule set on the basis of initializing the preset medical insurance rule realization class and acquiring the corresponding preset medical insurance rule initialization realization class, circularly calling all the preset medical insurance rule check methods contained in the preset medical insurance rule initialization realization class set according to the execution sequence of the preset medical insurance check rules from front to back, checking the medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule check method so as to check all the medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule initialization realization class set, therefore, the medical insurance case diagnosis and treatment information is audited, and a medical insurance information audit result corresponding to the medical insurance case diagnosis and treatment information is obtained, wherein the medical insurance information audit result can be that the audit is passed or that the audit is not passed.
Further, the step of circulating all the preset medical insurance rule verification methods included in the preset medical insurance rule initialization realization class set to verify all the medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule initialization realization class set includes:
and circularly presetting a medical insurance audit Bean interface set, sequentially calling a preset medical insurance rule checking method contained in the preset medical insurance audit Bean interface set, and checking all medical insurance case diagnosis and treatment information corresponding to the preset medical insurance audit Bean interface set, wherein the preset medical insurance rule checking method is realized by instantiating a preset medical insurance audit Bean interface.
Specifically, when medical insurance check rules are adopted to check medical insurance case diagnosis and treatment information, a preset medical insurance audit Bean interface mode is adopted to check the medical insurance rules, wherein the Bean is Spring type. Creating a preset medical insurance audit Bean interface, instantiating the preset medical insurance audit Bean interface according to medical insurance check rules corresponding to the preset medical insurance audit Bean interface to obtain a preset medical insurance rule initialization implementation class corresponding to the preset medical insurance audit Bean interface, wherein the preset medical insurance rule initialization implementation class is used for describing a preset medical insurance rule check method of a specific medical insurance check rule, different instantiation can be performed on the same preset medical insurance audit Bean interface to obtain different preset medical insurance rule check methods of the same preset medical insurance audit Bean interface, and instantiation of the preset medical insurance Bean interface can be performed based on a preset medical insurance audit Bean factory, for example, based on a Bean FactorPostProcessor factory mode, implementation classes of each medical insurance check rule are automatically initialized, and a plurality of instantiated preset medical insurance audit Bean interfaces form a preset medical audit Bean interface set, the method comprises the steps of obtaining a preset medical insurance rule initialization realization class set comprising a plurality of preset medical insurance rule initialization realization classes, wherein the preset medical insurance rule initialization realization class set comprises respective preset medical insurance rule checking methods of a plurality of medical insurance checking rules, then circularly presetting a medical insurance audit Bean interface set, sequentially calling the preset medical insurance rule checking methods contained in the preset medical insurance audit Bean interface set, checking all medical insurance case diagnosis and treatment information corresponding to the preset medical insurance audit Bean interface set, realizing medical insurance rule checking based on the Bean interface, and improving expandability and readability of medical insurance checking rules, thereby improving efficiency and auditing quality of medical insurance checking of major diseases.
According to the embodiment of the application, by acquiring the medical insurance case, the medical insurance case comprises medical insurance case identification and medical insurance case diagnosis and treatment information, the preset medical insurance audit rule list corresponding to the medical insurance case is acquired according to the medical insurance case identification, the preset medical insurance audit rule list comprises the preset medical insurance audit rule ID, the preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID is acquired according to the preset medical insurance audit rule ID, the medical insurance case diagnosis and treatment information is audited by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set, a large amount of audit data corresponding to major disease medical insurance in each area can be correspondingly set and checked, the audit efficiency of the major disease medical insurance can be improved, and further the risk early warning efficiency of the major disease medical insurance is improved.
Referring to fig. 6, fig. 6 is a fourth sub-flow schematic diagram of the medical insurance risk auditing method provided in the embodiment of the present application, and as shown in fig. 6, in this embodiment, the auditing the medical information of the medical insurance case by using the preset medical insurance check rule included in the preset medical insurance check rule set includes:
s15, judging whether the medical insurance case diagnosis and treatment information meets preset diagnosis and treatment conditions;
s16, if the medical information of the medical insurance case meets the preset medical condition, judging that the medical information of the medical insurance case passes the examination and verification;
and S17, if the medical information of the medical insurance case does not meet the preset diagnosis and treatment conditions, judging that the medical information of the medical insurance case is not approved.
Specifically, the corresponding preset diagnosis and treatment conditions can be set according to the diagnosis and treatment information of the medical insurance case, for example, the diagnosis and treatment object corresponding to the diagnosis and treatment information of the medical insurance case can be judged whether belongs to the content in the preset blacklist or not by aiming at the blacklist check, for example, whether the diagnosis and treatment hospital belongs to the preset hospital in the blacklist or not, whether the diagnosis and treatment doctor belongs to the preset doctor in the blacklist or not, and the like can be judged, the negative number check and the like can be further carried out on the appointed diagnosis and treatment information of the medical insurance case, so that whether the diagnosis and treatment information of the medical insurance case meets the preset diagnosis and treatment conditions or not can be judged according to the preset diagnosis and treatment conditions corresponding to the diagnosis and treatment information of the medical insurance case, if the diagnosis and treatment information of the medical insurance case meets the preset diagnosis and treatment conditions, the diagnosis and treatment information of the medical insurance case passes the audit, if the diagnosis and treatment information of the medical insurance case does not meet the preset diagnosis and treatment conditions, and judging that the medical insurance case diagnosis and treatment information is not approved, so that the medical insurance case diagnosis and treatment information is approved, and the efficiency of examining and treating the medical insurance of the major illness can be improved under the condition that the medical insurance deduction rule of the major illness is more.
Further, after the step of determining that the medical insurance case diagnosis and treatment information is not approved, the method further comprises the following steps:
and taking the medical information of the medical insurance case which is not approved as abnormal medical information, and carrying out early warning on the abnormal medical information.
Specifically, for medical and insurance case diagnosis and treatment information which is not approved, the medical and insurance case diagnosis and treatment information which is not approved is required to be used as abnormal diagnosis and treatment information, the abnormal diagnosis and treatment information is subjected to early warning, namely the abnormal diagnosis and treatment information is warned to remind relevant personnel controlling medical and insurance auditing risks to carry out further processing, early warning content for early warning can comprise an early warning title, early warning information description and an early warning auditing result, and the early warning content can also comprise medical and insurance case identification of the medical and insurance case, so that the relevant personnel can conveniently carry out further processing on the early warning content, and therefore auditing efficiency of medical and insurance auditing risks of major diseases is improved. In medical insurance for major diseases, aiming at medical insurance audit cases for major diseases, the early warning content can be displayed in a preset early warning display mode such as a preset early warning display list, and the preset early warning display mode can also include a preset highlight display mode corresponding to the preset content, for example, please refer to the following table 1, as an example shown in table 1, an audit result is highlighted in a thickening mode, or the audit result is displayed in a preset highlight mode, or the audit result is displayed in a preset color mode, so that relevant personnel can conveniently determine relevant key content, and the processing efficiency of medical insurance audit risk is improved.
Table 1
It should be noted that, the medical insurance risk auditing method described in the above embodiments may recombine the technical features included in different embodiments as needed to obtain a combined embodiment, but all of them are within the protection scope claimed in the present application.
Referring to fig. 7, fig. 7 is a schematic block diagram of a medical insurance risk auditing apparatus according to an embodiment of the present application. Corresponding to the medical insurance risk auditing method, the embodiment of the application also provides a medical insurance risk auditing device. As shown in fig. 7, the medical insurance risk auditing apparatus includes a unit for executing the medical insurance risk auditing method, and the medical insurance risk auditing apparatus may be configured in a computer device. Specifically, referring to fig. 7, the medical insurance risk auditing apparatus 70 includes a first obtaining unit 71, a second obtaining unit 72, a third obtaining unit 73, and an auditing unit 74.
The first obtaining unit 71 is configured to obtain a medical insurance case, where the medical insurance case includes medical insurance case identification and medical insurance case diagnosis and treatment information;
a second obtaining unit 72, configured to obtain a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identifier, where the preset medical insurance audit rule list includes a preset medical insurance audit rule ID;
a third obtaining unit 73, configured to obtain, according to the preset medical insurance audit rule ID, a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID;
and the auditing unit 74 is configured to audit the medical insurance case diagnosis and treatment information by using the preset medical insurance check rule included in the preset medical insurance check rule set.
In one embodiment, the first obtaining unit 71 includes:
the first receiving subunit is used for receiving medical insurance cases uploaded by a plurality of preset medical insurance case data sources;
the first writing subunit is used for writing the medical insurance case into a preset asynchronous case task processing table;
and the first polling subunit is used for polling the preset asynchronous case task processing table and acquiring the medical insurance case from the preset asynchronous case task processing table.
In one embodiment, the second obtaining unit 72 includes:
the first determining subunit is used for determining a preset medical insurance place to which the medical insurance case belongs according to the medical insurance case identifier;
the second determining subunit is used for determining a preset medical insurance project to which the medical insurance case belongs according to the preset medical insurance place;
the first obtaining subunit is configured to obtain, according to the preset medical insurance item, a preset medical insurance audit rule list corresponding to the preset medical insurance item, so as to obtain a preset medical insurance audit rule list corresponding to the medical insurance case.
In one embodiment, the auditing unit 74 includes:
the verification subunit is configured to initialize a realization class set based on a preset medical insurance rule corresponding to the preset medical insurance verification rule set, call a preset medical insurance rule initialization realization class included in the preset medical insurance rule initialization realization class set, and verify medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule verification method by using a preset medical insurance rule verification method corresponding to the preset medical insurance rule initialization realization class;
and the circulation subunit is used for circulating all the verification methods of the preset medical insurance rules contained in the initialization realization class set of the preset medical insurance rules and verifying all the medical information of the medical insurance cases corresponding to the initialization realization class set of the preset medical insurance rules.
In an embodiment, the circulation subunit is specifically configured to circulate a preset medical insurance audit Bean interface set, sequentially call a preset medical insurance rule checking method included in the preset medical insurance audit Bean interface set, and check all medical insurance case diagnosis and treatment information corresponding to the preset medical insurance audit Bean interface set, where the preset medical insurance rule checking method is implemented by instantiating a preset medical insurance audit Bean interface.
In one embodiment, the auditing unit 74 includes:
the judging subunit is used for judging whether the medical insurance case diagnosis and treatment information meets preset diagnosis and treatment conditions;
the first judging subunit is used for judging that the medical insurance case diagnosis and treatment information is approved if the medical insurance case diagnosis and treatment information meets preset diagnosis and treatment conditions;
and the second judgment subunit is used for judging that the medical insurance case diagnosis and treatment information is not approved if the medical insurance case diagnosis and treatment information does not meet the preset diagnosis and treatment conditions. .
In an embodiment, the medical insurance risk auditing apparatus 70 further includes:
and the early warning unit is used for taking the medical insurance case diagnosis and treatment information which is not passed by the examination as abnormal diagnosis and treatment information and early warning the abnormal diagnosis and treatment information.
It should be noted that, as can be clearly understood by those skilled in the art, the detailed implementation process of the medical insurance risk auditing apparatus and each unit may refer to the corresponding description in the foregoing method embodiment, and for convenience and brevity of description, no further description is provided here.
Meanwhile, the division and connection modes of the units in the medical insurance risk auditing device are only used for illustration, in other embodiments, the medical insurance risk auditing device can be divided into different units as required, and the units in the medical insurance risk auditing device can also adopt different connection sequences and modes to complete all or part of the functions of the medical insurance risk auditing device.
The medical insurance risk auditing means may be implemented in the form of a computer program which can be run on a computer device as shown in fig. 8.
Referring to fig. 8, fig. 8 is a schematic block diagram of a computer device according to an embodiment of the present application. The computer device 500 may be a computer device such as a desktop computer or a server, or may be a component or part of another device.
Referring to fig. 8, the computer device 500 includes a processor 502, a memory, which may include a non-volatile storage medium 503 and an internal memory 504, which may also be a volatile storage medium, and a network interface 505 connected by a system bus 501.
The non-volatile storage medium 503 may store an operating system 5031 and a computer program 5032. The computer program 5032, when executed, causes the processor 502 to perform a method for auditing a medical insurance risk as described above.
The processor 502 is used to provide computing and control capabilities to support the operation of the overall computer device 500.
The internal memory 504 provides an environment for the operation of the computer program 5032 in the non-volatile storage medium 503, and when the computer program 5032 is executed by the processor 502, the processor 502 may be enabled to perform a method for auditing medical insurance risks.
The network interface 505 is used for network communication with other devices. Those skilled in the art will appreciate that the configuration shown in fig. 8 is a block diagram of only a portion of the configuration relevant to the present teachings and does not constitute a limitation on the computer device 500 to which the present teachings may be applied, and that a particular computer device 500 may include more or less components than those shown, or combine certain components, or have a different arrangement of components. For example, in some embodiments, the computer device may only include a memory and a processor, and in such embodiments, the structures and functions of the memory and the processor are consistent with those of the embodiment shown in fig. 8, and are not described herein again.
Wherein the processor 502 is configured to run the computer program 5032 stored in the memory to implement the following steps: acquiring a medical insurance case, wherein the medical insurance case comprises medical insurance case identification and medical insurance case diagnosis and treatment information; acquiring a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identification, wherein the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID; acquiring a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID according to the preset medical insurance audit rule ID; and auditing the medical insurance case diagnosis and treatment information by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set.
In an embodiment, when the processor 502 implements the acquiring of the medical insurance case, the following steps are specifically implemented:
receiving medical insurance cases uploaded by a plurality of preset medical insurance case data sources;
writing the medical insurance case into a preset asynchronous case task processing table;
polling the preset asynchronous case task processing table, and acquiring medical insurance cases from the preset asynchronous case task processing table.
In an embodiment, when the processor 502 obtains the preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identifier, the following steps are specifically implemented:
determining a preset medical insurance place to which the medical insurance case belongs according to the medical insurance case identification;
determining a preset medical insurance project to which the medical insurance case belongs according to the place to which the preset medical insurance belongs;
and acquiring a preset medical insurance audit rule list corresponding to the preset medical insurance project according to the preset medical insurance project so as to obtain a preset medical insurance audit rule list corresponding to the medical insurance case.
In an embodiment, when the processor 502 implements the auditing of the medical insurance case diagnosis and treatment information by using the preset medical insurance check rule included in the preset medical insurance check rule set, the following steps are specifically implemented:
initializing a realization class set based on a preset medical insurance rule corresponding to the preset medical insurance check rule set, calling a preset medical insurance rule initialization realization class contained in the preset medical insurance rule initialization realization class set, and checking medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule check method by adopting a preset medical insurance rule check method corresponding to the preset medical insurance rule initialization realization class;
and circulating all the verification methods of the preset medical insurance rules contained in the initialization realization class set of the preset medical insurance rules, and verifying all the medical insurance case diagnosis and treatment information corresponding to the initialization realization class set of the preset medical insurance rules.
In an embodiment, when the processor 502 implements the method for verifying all the preset medical insurance rules included in the cyclic initialization realization class set of the preset medical insurance rules and verifies all the medical information of the medical insurance cases corresponding to the initialization realization class set of the preset medical insurance rules, the following steps are specifically implemented:
and circularly presetting a medical insurance audit Bean interface set, sequentially calling a preset medical insurance rule checking method contained in the preset medical insurance audit Bean interface set, and checking all medical insurance case diagnosis and treatment information corresponding to the preset medical insurance audit Bean interface set, wherein the preset medical insurance rule checking method is realized by instantiating a preset medical insurance audit Bean interface.
In an embodiment, when the processor 502 implements the auditing of the medical insurance case diagnosis and treatment information by using the preset medical insurance check rule included in the preset medical insurance check rule set, the following steps are specifically implemented:
judging whether the medical insurance case diagnosis and treatment information meets preset diagnosis and treatment conditions;
if the medical information of the medical insurance case meets the preset diagnosis and treatment conditions, judging that the medical information of the medical insurance case passes the examination and verification;
and if the medical insurance case diagnosis and treatment information does not meet the preset diagnosis and treatment conditions, judging that the medical insurance case diagnosis and treatment information is not approved. .
In an embodiment, after the processor 502 determines that the medical insurance case diagnosis and treatment information audit is not passed, the following steps are further implemented:
and taking the medical information of the medical insurance case which is not approved as abnormal medical information, and carrying out early warning on the abnormal medical information.
It should be understood that in the embodiment of the present Application, the Processor 502 may be a Central Processing Unit (CPU), and the Processor 502 may also be other general-purpose processors, Digital Signal Processors (DSPs), Application Specific Integrated Circuits (ASICs), Field Programmable Gate Arrays (FPGAs) or other Programmable logic devices, discrete Gate or transistor logic devices, discrete hardware components, and the like. Wherein a general purpose processor may be a microprocessor or the processor may be any conventional processor or the like.
It will be understood by those skilled in the art that all or part of the processes in the method for implementing the above embodiments may be implemented by a computer program, and the computer program may be stored in a computer readable storage medium. The computer program is executed by at least one processor in the computer system to implement the flow steps of the embodiments of the method described above.
Accordingly, the present application also provides a computer-readable storage medium. The computer-readable storage medium may be a non-volatile computer-readable storage medium or a volatile computer-readable storage medium, the computer-readable storage medium storing a computer program that, when executed by a processor, causes the processor to perform the steps of:
a computer program product which, when run on a computer, causes the computer to perform the steps of the medical insurance risk auditing method described in the embodiments above.
The computer readable storage medium may be an internal storage unit of the aforementioned device, such as a hard disk or a memory of the device. The computer readable storage medium may also be an external storage device of the device, such as a plug-in hard disk, a Smart Media Card (SMC), a Secure Digital (SD) Card, a Flash memory Card (Flash Card), etc. provided on the device. Further, the computer-readable storage medium may also include both an internal storage unit and an external storage device of the apparatus.
It is clear to those skilled in the art that, for convenience and brevity of description, the specific working processes of the above-described apparatuses, devices and units may refer to the corresponding processes in the foregoing method embodiments, and are not described herein again.
The storage medium is an entity and non-transitory storage medium, and may be various entity storage media capable of storing computer programs, such as a usb disk, a removable hard disk, a Read-only memory (ROM), a magnetic disk, or an optical disk.
Those of ordinary skill in the art will appreciate that the elements and algorithm steps of the examples described in connection with the embodiments disclosed herein may be embodied in electronic hardware, computer software, or combinations of both, and that the components and steps of the examples have been described in a functional general in the foregoing description for the purpose of illustrating clearly the interchangeability of hardware and software. Whether such functionality is implemented as hardware or software depends upon the particular application and design constraints imposed on the implementation. Skilled artisans may implement the described functionality in varying ways for each particular application, but such implementation decisions should not be interpreted as causing a departure from the scope of the present application.
In the several embodiments provided in the present application, it should be understood that the disclosed apparatus and method may be implemented in other ways. For example, the above-described apparatus embodiments are merely illustrative. For example, the division of each unit is only one logic function division, and there may be another division manner in actual implementation. For example, various elements or components may be combined or may be integrated into another system, or some features may be omitted, or not implemented.
The steps in the method of the embodiment of the application can be sequentially adjusted, combined and deleted according to actual needs. The units in the device of the embodiment of the application can be combined, divided and deleted according to actual needs. In addition, functional units in the embodiments of the present application may be integrated into one processing unit, or each unit may exist alone physically, or two or more units are integrated into one unit.
The integrated unit, if implemented in the form of a software functional unit and sold or used as a stand-alone product, may be stored in a storage medium. Based on such understanding, the technical solution of the present application may be substantially implemented or contributed to by the prior art, or all or part of the technical solution may be embodied in a software product, which is stored in a storage medium and includes instructions for causing an electronic device (which may be a personal computer, a terminal, or a network device) to perform all or part of the steps of the method according to the embodiments of the present application.
The above description is only for the specific embodiments of the present application, but the scope of the present application is not limited thereto, and any person skilled in the art can easily conceive various equivalent modifications or substitutions within the technical scope of the present application, and these modifications or substitutions should be covered by the scope of the present application. Therefore, the protection scope of the present application shall be subject to the protection scope of the claims.
Claims (10)
1. A medical insurance risk auditing method is characterized by comprising the following steps:
acquiring a medical insurance case, wherein the medical insurance case comprises medical insurance case identification and medical insurance case diagnosis and treatment information;
acquiring a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identification, wherein the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID;
acquiring a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID according to the preset medical insurance audit rule ID;
and auditing the medical insurance case diagnosis and treatment information by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set.
2. The medical insurance risk auditing method of claim 1 where the acquiring medical insurance cases includes:
receiving medical insurance cases uploaded by a plurality of preset medical insurance case data sources;
writing the medical insurance case into a preset asynchronous case task processing table;
polling the preset asynchronous case task processing table, and acquiring medical insurance cases from the preset asynchronous case task processing table.
3. The medical insurance risk auditing method according to claim 1, wherein the obtaining of a preset medical insurance auditing rule list corresponding to the medical insurance case according to the medical insurance case identification comprises:
determining a preset medical insurance place to which the medical insurance case belongs according to the medical insurance case identification;
determining a preset medical insurance project to which the medical insurance case belongs according to the place to which the preset medical insurance belongs;
and acquiring a preset medical insurance audit rule list corresponding to the preset medical insurance project according to the preset medical insurance project so as to obtain a preset medical insurance audit rule list corresponding to the medical insurance case.
4. The medical insurance risk auditing method according to claim 1, wherein the auditing the medical insurance case diagnosis and treatment information using a preset medical insurance check rule contained in the preset medical insurance check rule set includes:
initializing a realization class set based on a preset medical insurance rule corresponding to the preset medical insurance check rule set, calling a preset medical insurance rule initialization realization class contained in the preset medical insurance rule initialization realization class set, and checking medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule check method by adopting a preset medical insurance rule check method corresponding to the preset medical insurance rule initialization realization class;
and circulating all the verification methods of the preset medical insurance rules contained in the initialization realization class set of the preset medical insurance rules, and verifying all the medical insurance case diagnosis and treatment information corresponding to the initialization realization class set of the preset medical insurance rules.
5. The medical insurance risk auditing method according to claim 4, wherein the circulating all the preset medical insurance rule verification methods included in the preset medical insurance rule initialization realization class set, and the verifying all the medical insurance case diagnosis and treatment information corresponding to the preset medical insurance rule initialization realization class set includes:
and circularly presetting a medical insurance audit Bean interface set, sequentially calling a preset medical insurance rule checking method contained in the preset medical insurance audit Bean interface set, and checking all medical insurance case diagnosis and treatment information corresponding to the preset medical insurance audit Bean interface set, wherein the preset medical insurance rule checking method is realized by instantiating a preset medical insurance audit Bean interface.
6. The medical insurance risk auditing method according to claim 1, wherein the auditing the medical insurance case diagnosis and treatment information using a preset medical insurance check rule contained in the preset medical insurance check rule set includes:
judging whether the medical insurance case diagnosis and treatment information meets preset diagnosis and treatment conditions;
if the medical information of the medical insurance case meets the preset diagnosis and treatment conditions, judging that the medical information of the medical insurance case passes the examination and verification;
and if the medical insurance case diagnosis and treatment information does not meet the preset diagnosis and treatment conditions, judging that the medical insurance case diagnosis and treatment information is not approved.
7. The medical insurance risk auditing method according to claim 6, wherein after determining that the medical information auditing of the medical insurance case is not passed, further comprising:
and taking the medical information of the medical insurance case which is not approved as abnormal medical information, and carrying out early warning on the abnormal medical information.
8. A medical insurance risk auditing apparatus, the apparatus comprising:
the medical insurance case identification and diagnosis and treatment system comprises a first acquisition unit and a second acquisition unit, wherein the first acquisition unit is used for acquiring a medical insurance case which comprises medical insurance case identification and medical insurance case diagnosis and treatment information;
the second obtaining unit is used for obtaining a preset medical insurance audit rule list corresponding to the medical insurance case according to the medical insurance case identification, wherein the preset medical insurance audit rule list comprises a preset medical insurance audit rule ID;
a third obtaining unit, configured to obtain, according to the preset medical insurance audit rule ID, a preset medical insurance check rule set corresponding to the preset medical insurance audit rule ID;
and the auditing unit is used for auditing the medical insurance case diagnosis and treatment information by adopting the preset medical insurance check rule contained in the preset medical insurance check rule set.
9. A computer device, comprising a memory and a processor coupled to the memory; the memory is used for storing a computer program; the processor is adapted to run the computer program to perform the steps of the method according to any of claims 1-7.
10. A computer-readable storage medium, characterized in that the storage medium stores a computer program which, when being executed by a processor, realizes the steps of the method according to any one of claims 1 to 7.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN202111012440.5A CN113706321A (en) | 2021-08-31 | 2021-08-31 | Medical insurance risk auditing method and device, computer equipment and readable storage medium |
Applications Claiming Priority (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN202111012440.5A CN113706321A (en) | 2021-08-31 | 2021-08-31 | Medical insurance risk auditing method and device, computer equipment and readable storage medium |
Publications (1)
| Publication Number | Publication Date |
|---|---|
| CN113706321A true CN113706321A (en) | 2021-11-26 |
Family
ID=78658009
Family Applications (1)
| Application Number | Title | Priority Date | Filing Date |
|---|---|---|---|
| CN202111012440.5A Pending CN113706321A (en) | 2021-08-31 | 2021-08-31 | Medical insurance risk auditing method and device, computer equipment and readable storage medium |
Country Status (1)
| Country | Link |
|---|---|
| CN (1) | CN113706321A (en) |
Citations (6)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| IES20080075A2 (en) * | 2007-02-01 | 2008-11-12 | Slainte Technologies Ltd | A medical insurance reconciliation product |
| CN105118003A (en) * | 2015-07-31 | 2015-12-02 | 中国太平洋保险（集团）股份有限公司 | Intelligent auditing system and auditing algorithm for serious illness medical insurance |
| KR20170121952A (en) * | 2016-04-26 | 2017-11-03 | (주)프리원 | Device and method for claiming insurance |
| CN109345200A (en) * | 2018-09-20 | 2019-02-15 | 沈阳金域医学检验所有限公司 | Automatic auditing method and device, computer readable storage medium based on high-volume report |
| CN111813399A (en) * | 2020-07-23 | 2020-10-23 | 平安医疗健康管理股份有限公司 | Machine learning-based auditing rule processing method and device and computer equipment |
| CN111815467A (en) * | 2020-08-20 | 2020-10-23 | 支付宝(杭州)信息技术有限公司 | Auditing method and device |
-
2021
- 2021-08-31 CN CN202111012440.5A patent/CN113706321A/en active Pending
Patent Citations (6)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| IES20080075A2 (en) * | 2007-02-01 | 2008-11-12 | Slainte Technologies Ltd | A medical insurance reconciliation product |
| CN105118003A (en) * | 2015-07-31 | 2015-12-02 | 中国太平洋保险（集团）股份有限公司 | Intelligent auditing system and auditing algorithm for serious illness medical insurance |
| KR20170121952A (en) * | 2016-04-26 | 2017-11-03 | (주)프리원 | Device and method for claiming insurance |
| CN109345200A (en) * | 2018-09-20 | 2019-02-15 | 沈阳金域医学检验所有限公司 | Automatic auditing method and device, computer readable storage medium based on high-volume report |
| CN111813399A (en) * | 2020-07-23 | 2020-10-23 | 平安医疗健康管理股份有限公司 | Machine learning-based auditing rule processing method and device and computer equipment |
| CN111815467A (en) * | 2020-08-20 | 2020-10-23 | 支付宝(杭州)信息技术有限公司 | Auditing method and device |
Similar Documents
| Publication | Publication Date | Title |
|---|---|---|
| JP6878578B2 (en) | Systems and methods for anonymizing health data and modifying and editing health data across geographic areas for analysis | |
| US20200222020A1 (en) | Imaging protocol manager pushing systems and methods | |
| US20170192803A1 (en) | Dynamic Determination of Local and Remote API Calls | |
| US8375427B2 (en) | Holistic risk-based identity establishment for eligibility determinations in context of an application | |
| CN111883222B (en) | Text data error detection method and device, terminal equipment and storage medium | |
| US11087877B1 (en) | Identifying anomalous brain data | |
| CN111985197B (en) | Template generation method based on medical information | |
| EP4026135A1 (en) | System for protecting and anonymizing personal data | |
| CN115437933A (en) | Automatic testing method and device, computer equipment and storage medium | |
| US11324401B1 (en) | Computing system for wound tracking | |
| CN112927152B (en) | CT image denoising processing method, device, computer equipment and medium | |
| CN113961609A (en) | Data query method, device, server and storage medium | |
| CN114005498A (en) | Clinical test data logic checking method and device, equipment and storage medium | |
| CA2930525A1 (en) | Clinical trial data capture | |
| CN113706321A (en) | Medical insurance risk auditing method and device, computer equipment and readable storage medium | |
| CN115910265A (en) | Paperless medical record generation method and system for hospital | |
| CN115543428A (en) | Simulated data generation method and device based on strategy template | |
| CN114491196A (en) | Information granularity-based information export method, device, equipment and medium | |
| CN112395575A (en) | Authority management method, device, equipment and storage medium | |
| US10521552B2 (en) | Method and computing device for implementing multiple matching strategies | |
| CN117648718B (en) | Business object display method and device based on data source, electronic equipment and medium | |
| CN109285599A (en) | Failure parameter is provided in medicine cloud infrastructure | |
| US20230298083A1 (en) | Commerce-based shopping experience with digital twin simulation infusion | |
| CN111754196B (en) | Configuration method, device and storage medium of application flow of disabled assistive device | |
| Tounsi et al. | Modeling IoT Design Patterns Proven Correct by Construction |
Legal Events
| Date | Code | Title | Description |
|---|---|---|---|
| PB01 | Publication | ||
| PB01 | Publication | ||
| SE01 | Entry into force of request for substantive examination | ||
| SE01 | Entry into force of request for substantive examination | ||
| WD01 | Invention patent application deemed withdrawn after publication | ||
| WD01 | Invention patent application deemed withdrawn after publication |
Application publication date: 20211126 |