CN113780792A - Medical insurance violation monitoring method and device and computer readable storage medium - Google Patents
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Abstract
The invention relates to the technical field of medical insurance monitoring, in particular to a method and a device for monitoring medical insurance violation behaviors and a computer-readable storage medium, and aims to solve the problem of how to effectively prevent the medical insurance violation behaviors. For this purpose, the medical insurance violation monitoring method comprises the following steps: aiming at each clinic stage, acquiring a site image and generated clinic information of a medical insurance participant in the clinic stage, wherein the clinic information comprises a diagnosis result and a diagnosis and treatment scheme; comparing the identities of the medical insurance participants according to the field images, and/or judging whether the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result; and if the identity comparison result is abnormal and/or the diagnosis and treatment scheme is judged to belong to the violation scheme, determining that medical insurance violation behaviors exist. By monitoring each clinic stage, the site image and the clinic information are obtained, and the site image and the clinic information are respectively analyzed to confirm the medical insurance violation and send an alarm, so that the medical insurance violation is effectively avoided.
Description
Technical Field
The invention relates to the technical field of medical insurance monitoring, and particularly provides a method and a device for monitoring medical insurance violation behaviors and a computer-readable storage medium.
Background
The medical insurance (abbreviated as 'medical insurance') is insurance which takes the occurrence of medical behaviors agreed by insurance contracts as insurance payment conditions and provides guarantee for medical expenses during the period that an insured person receives a diagnosis and treatment, and in brief, the medical insurance can be used by people during the treatment to reduce the treatment expenses. However, many medical insurance violations exist, such as impersonation hospitalization, false treatment, medical insurance card embezzlement and the like, the involved personnel not only are patients, but also include medical institutions and medical staff and the like, and the medical insurance violations cause continuous loss of medical insurance funds and bring great challenges to sustainable development of the medical insurance funds. In the prior art, medical insurance violation behaviors are generally supervised by manpower, the force of manual supervision is far from enough for the infinite cheating and insurance means, and the medical insurance violation behaviors related to medical structures and medical personnel cannot be avoided.
Accordingly, there is a need in the art for a new medical insurance violation monitoring solution that addresses the above-mentioned problems.
Disclosure of Invention
The invention aims to solve the technical problem, namely, the problem of how to effectively monitor medical insurance violation.
In a first aspect, the present invention provides a method for monitoring medical insurance violation, including:
acquiring a site image of a medical insurance participant in each clinic stage and generated clinic information, wherein the clinic information comprises a diagnosis result and a diagnosis and treatment scheme;
comparing the identities of the medical insurance participants according to the field image, and/or,
judging whether the diagnosis and treatment scheme belongs to an illegal scheme corresponding to the diagnosis result;
and if the identity comparison result is abnormal and/or the diagnosis and treatment scheme is judged to belong to the illegal scheme, determining that medical insurance illegal behaviors exist.
In one technical solution of the method for monitoring medical insurance infraction, the method further includes the following steps:
respectively determining medical insurance violation types corresponding to the identity comparison result and the diagnosis and treatment scheme;
searching an alarm level corresponding to the medical insurance violation type in a preset alarm level library;
alarming according to the alarm level;
and/or the like and/or,
the step of determining whether the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result specifically includes:
acquiring violation scheme judgment conditions corresponding to the diagnosis result from a preset rule base;
judging whether the diagnosis and treatment scheme meets the rule-breaking scheme judgment condition or not;
if so, judging that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result; if not, judging that the diagnosis and treatment scheme does not belong to the violation scheme corresponding to the diagnosis result.
In one technical solution of the medical insurance violation monitoring method, the method further includes correcting the violation scheme determination condition by the following steps:
after judging that the diagnosis and treatment scheme belongs to the illegal scheme, judging whether a misjudgment correction instruction aiming at the diagnosis and treatment scheme is received or not;
if so, adjusting the diagnosis and treatment scheme to be a non-violation scheme according to the misjudgment correction instruction, and correcting the violation scheme judgment condition according to the diagnosis and treatment scheme;
and/or the like and/or,
when the medical insurance participation object comprises a medical insurance visit staff and the visit stage is an inpatient/treatment stage, the violation scheme judgment condition comprises the following steps:
the real hospitalization duration of the nursing personnel is longer than the preset hospitalization duration corresponding to the diagnosis result;
the real hospitalization times of the nursing personnel in the preset time length are larger than the preset hospitalization times corresponding to the diagnosis result.
In one technical scheme of the method for monitoring medical insurance violation, when the medical insurance participant comprises an insurance visit staff and the visit stage is an outpatient service payment stage, the step of comparing the identities of the medical insurance participant according to the field image specifically comprises the following steps:
judging whether the face images related to the personnel participating in the medical care already contain the face images which are expressed as the same personnel as the live images;
when the identity comparison result is contained, judging that the identity comparison result is not abnormal;
when the face images are not included, continuously judging whether the number of the face images related to the insured visit personnel is smaller than a preset threshold value;
if so, judging that the identity comparison result is abnormal, and associating the field image with the visit personnel as a new face image associated with the visit personnel;
if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participating object comprises medical staff, the step of comparing the identities of the medical insurance participating object according to the field image specifically comprises the following steps:
step S1: matching the face according to the field image of the medical staff and the face image related to the medical staff; if the face matching is successful, go to step S2; if the face matching fails, judging that the identity comparison result is abnormal;
step S2: judging whether a site image of a medical staff attending a doctor related to the doctor information is acquired or not after the doctor information is detected to be generated by the medical staff aiming at the doctor attending the doctor; if yes, go to step S3; if not, judging that the identity comparison result is abnormal;
step S3: carrying out face matching according to the live images of the attendants and the face images related to the attendants; if the face matching fails, judging that the identity comparison result is abnormal; if the face matching is successful, go to step S4;
step S4: judging whether the medical personnel has the authority of generating the visit information; if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participant is an insurance visit staff and the visit stage is an hospitalization/treatment stage, the step of comparing the identities of the medical insurance participant according to the live image specifically comprises the following steps:
acquiring the visit information of the visit attendants to determine the hospitalization/treatment time of the visit attendants;
judging whether the face images associated with the medical personnel are acquired and represented as the on-site images of the same personnel within the hospitalization/treatment time;
if not, judging that the identity comparison result is abnormal.
In one technical scheme of the method for monitoring medical insurance violation, the medical insurance participating objects include medical staff, medical staff and medical institutions, and the method further includes:
respectively establishing a medical insurance monitoring file for each medical insurance participating object;
the medical insurance monitoring files of the medical insurance visitors at least comprise identity information of the medical insurance visitors, face images related to the medical insurance visitors, the medical time, the medical place, medical staff and medical information during the medical treatment;
the medical insurance monitoring file of the medical staff at least comprises identity information of the medical staff, a face image related to the medical staff, a medical institution, a diagnosis and treatment range, diagnosis and treatment time, a diagnosis and treatment object and diagnosis and treatment information;
the medical insurance monitoring file of the medical institution at least comprises medical insurance monitoring files of each medical staff and each medical staff in the medical institution.
In one technical scheme of the method for monitoring the medical insurance violation, after the medical insurance participant is determined to have the medical insurance violation, the warning information of the medical insurance violation is uploaded to a preset credit evaluation system;
the warning information at least comprises the medical insurance violation type of the medical insurance participant;
and/or the like and/or,
the method further comprises the following steps:
responding to a complaint instruction aiming at the alarm information, sending a complaint request of the illegal action of the medical insurance to a preset medical insurance supervision platform, and receiving response information fed back by the medical insurance supervision platform according to the complaint request of the illegal action of the medical insurance.
In a second aspect, the present invention provides a medical insurance violation monitoring apparatus, including: a data acquisition module configured to acquire, for each visit stage, a live image of a medical insurance participant in the visit stage and generated visit information, wherein the visit information includes a diagnosis result and a diagnosis and treatment plan;
a violation verification module configured to compare identities of the medical insurance participants according to the live image, and/or,
judging whether the diagnosis and treatment scheme belongs to an illegal scheme corresponding to the diagnosis result;
and the medical insurance violation determining module is configured to determine that medical insurance violation exists if the identity comparison result is abnormal and/or the diagnosis and treatment scheme is judged to belong to a violation scheme.
In one technical solution of the above medical insurance violation monitoring apparatus, the medical insurance violation determining module is further configured to perform the following operations to alarm the medical insurance violation:
respectively determining medical insurance violation types corresponding to the identity comparison result and the diagnosis and treatment scheme;
searching an alarm level corresponding to the medical insurance violation type in a preset alarm level library;
alarming according to the alarm level;
and/or the like and/or,
the violation verification module is further configured to perform the following:
acquiring violation scheme judgment conditions corresponding to the diagnosis result from a preset rule base;
judging whether the diagnosis and treatment scheme meets the rule-breaking scheme judgment condition or not;
if so, judging that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result; if not, judging that the diagnosis and treatment scheme does not belong to the violation scheme corresponding to the diagnosis result.
In one technical solution of the medical insurance violation monitoring apparatus, the violation verification module is further configured to perform the following operations:
after judging that the diagnosis and treatment scheme belongs to the illegal scheme, judging whether a misjudgment correction instruction aiming at the diagnosis and treatment scheme is received or not;
if so, adjusting the diagnosis and treatment scheme to be a non-violation scheme according to the misjudgment correction instruction, and correcting the violation scheme judgment condition according to the diagnosis and treatment scheme;
and/or the like and/or,
when the medical insurance participation object comprises a medical insurance visit staff and the visit stage is an inpatient/treatment stage, the violation scheme judgment condition comprises the following steps:
the real hospitalization duration of the nursing personnel is longer than the preset hospitalization duration corresponding to the diagnosis result;
the real hospitalization times of the nursing personnel in the preset time length are larger than the preset hospitalization times corresponding to the diagnosis result.
In one technical solution of the medical insurance violation monitoring apparatus, when the medical insurance participant includes an insurance visit staff and the visit stage is an outpatient payment stage, the violation verification module is configured to perform the following operations:
judging whether the face images related to the personnel participating in the medical care already contain the face images which are expressed as the same personnel as the live images;
when the identity comparison result is contained, judging that the identity comparison result is not abnormal;
when the face images are not included, continuously judging whether the number of the face images related to the insured visit personnel is smaller than a preset threshold value;
if so, judging that the identity comparison result is abnormal, and associating the field image with the visit personnel as a new face image associated with the visit personnel;
if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participant comprises a healthcare worker, the violation verification module is configured to:
step S1: matching the face according to the field image of the medical staff and the face image related to the medical staff; if the face matching is successful, go to step S2; if the face matching fails, judging that the identity comparison result is abnormal;
step S2: judging whether a site image of a medical staff attending a doctor related to the doctor information is acquired or not after the doctor information is detected to be generated by the medical staff aiming at the doctor attending the doctor; if yes, go to step S3; if not, judging that the identity comparison result is abnormal;
step S3: carrying out face matching according to the live images of the attendants and the face images related to the attendants; if the face matching fails, judging that the identity comparison result is abnormal; if the face matching is successful, go to step S4;
step S4: judging whether the medical personnel has the authority of generating the visit information; if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participant comprises an insurance visit and the visit stage is an hospitalization/treatment stage, the violation verification module is configured to:
acquiring the visit information of the visit attendants to determine the hospitalization/treatment time of the visit attendants;
judging whether the face images associated with the medical personnel are acquired and represented as the on-site images of the same personnel within the hospitalization/treatment time;
if not, judging that the identity comparison result is abnormal.
In a third aspect, a control device is provided, which includes a processor and a storage device, where the storage device is adapted to store a plurality of program codes, and the program codes are adapted to be loaded and run by the processor to execute the medical insurance violation monitoring method according to any one of the above technical solutions.
In a fourth aspect, a computer-readable storage medium is provided, where a plurality of program codes are stored, where the program codes are adapted to be loaded and executed by a processor to execute the medical insurance violation monitoring method according to any one of the above technical solutions of the medical insurance violation monitoring method.
Under the condition of adopting the technical scheme, the invention can acquire the site image and the visit information of the medical insurance participator in the visit stage aiming at each visit stage, the visit information can comprise a diagnosis result and a diagnosis and treatment scheme, whether the site image and the medical insurance participator are the same person or whether the medical insurance participator come to the site can be confirmed by comparing the identities of the site image and the medical insurance participator, whether the diagnosis and treatment scheme is an illegal scheme corresponding to the diagnosis result can be judged, the medical insurance violation can be determined and an alarm can be given after the identity comparison result is abnormal or the diagnosis and treatment scheme belongs to the illegal scheme, the identity of the medical insurance participator can be verified by the method, the medical insurance violation can be effectively monitored in each visit stage, and the medical insurance violation can be avoided, and medical insurance violation is effectively prevented.
Drawings
The disclosure of the present invention will become more readily understood with reference to the accompanying drawings. As is readily understood by those skilled in the art: these drawings are for illustrative purposes only and are not intended to constitute a limitation on the scope of the present invention. Moreover, in the drawings, like numerals are used to indicate like parts, and in which:
FIG. 1 is a flow chart illustrating the main steps of a medical insurance violation monitoring method according to an embodiment of the present invention;
FIG. 2 is a schematic diagram illustrating an identity comparison process in an outpatient payment phase of a medical insurance violation monitoring method according to an embodiment of the present invention;
FIG. 3 is a schematic flow chart illustrating the identity comparison of medical personnel for a medical insurance violation monitoring method according to one embodiment of the present invention;
FIG. 4 is a schematic diagram illustrating an identity comparison flow during the hospitalization/treatment phase of a medical insurance violation monitoring method according to an embodiment of the present invention;
FIG. 5 is a flow diagram illustrating an alarm of a medical insurance violation monitoring method according to one embodiment of the present invention;
FIG. 6 is a flow diagram illustrating an illegal protocol verification method of a medical insurance violation monitoring method according to one embodiment of the present invention;
fig. 7 is a schematic flow chart illustrating a process of correcting an illegal scheme judgment condition of the medical insurance violation monitoring method according to an embodiment of the present invention;
fig. 8 is a schematic diagram of a main structure of a medical insurance violation monitoring apparatus according to an embodiment of the present invention.
List of reference numerals：
81: a data acquisition module; 82: a violation verification module; 83: and a medical insurance violation determining module.
Detailed Description
Some embodiments of the invention are described below with reference to the accompanying drawings. It should be understood by those skilled in the art that these embodiments are only for explaining the technical principle of the present invention, and are not intended to limit the scope of the present invention.
In the description of the present invention, a "module" or "processor" may include hardware, software, or a combination of both. A module may comprise hardware circuitry, various suitable sensors, communication ports, memory, may comprise software components such as program code, or may be a combination of software and hardware. The processor may be a central processing unit, microprocessor, image processor, digital signal processor, or any other suitable processor. The processor has data and/or signal processing functionality. The processor may be implemented in software, hardware, or a combination thereof. Non-transitory computer readable storage media include any suitable medium that can store program code, such as magnetic disks, hard disks, optical disks, flash memory, read-only memory, random-access memory, and the like. The term "a and/or B" denotes all possible combinations of a and B, such as a alone, B alone or a and B. The term "at least one A or B" or "at least one of A and B" means similar to "A and/or B" and may include only A, only B, or both A and B. The singular forms "a", "an" and "the" may include the plural forms as well.
At present, the traditional medical insurance violation monitoring method generally depends on manual work, but for medical institutions, a large number of patients and family members thereof cause rapid increase of people, the workload is also rapidly increased at any time, and the means of deceiving and protecting are endless, under the condition, the medical insurance violation is unrealistic to be supervised by manual work, and under some conditions, medical staff and even medical institutions are possibly involved instead of the patients and the family members, which increases the difficulty of supervision of the medical insurance violation, and even can not avoid the medical insurance violation.
In the embodiment of the invention, the site image of the medical insurance participant in the treatment stage and the generated treatment information can be acquired for each treatment stage, the treatment information can comprise a treatment result and a treatment scheme, then the medical insurance participant is subjected to identity comparison according to the site image to confirm the identity of the medical insurance participant and also confirm whether the treatment scheme belongs to an illegal scheme corresponding to the diagnosis result, and when the identity comparison result is abnormal or the treatment scheme belongs to the illegal scheme, the medical insurance violation can be confirmed and an alarm is given.
In an example of an application scenario of the present invention, when a certain patient pays at a medical institution, a live image of the patient may be obtained, and then compared with a face image in a medical insurance card used by the patient, and if the comparison result is abnormal, it may be determined that an illegal action exists. Or when a certain patient visits at a certain doctor, the diagnosis result of the doctor on the patient is the disease condition A, the diagnosis and treatment scheme given by the patient is the diagnosis and treatment scheme of the disease condition B, at the moment, the diagnosis and treatment scheme can be determined to be an illegal scheme, the illegal action of medical insurance is determined, and an alarm is given.
Referring to fig. 1, fig. 1 is a flow chart illustrating main steps of a medical insurance violation method according to an embodiment of the invention. As shown in fig. 1, the medical insurance violation method in the embodiment of the present invention mainly includes the following steps S101 to S104.
Step S101: for each visit stage, a live image of the medical insurance participant in the visit stage and generated visit information are acquired, wherein the visit information may include a diagnosis result and a diagnosis and treatment plan.
The subject of medical insurance participation is not limited to "patient", but may be a medical staff such as a doctor, a nurse, or the like, or a medical structure. The visit session may be every scenario involving a medical insurance, such as an outpatient, a payment, an in-patient, and so on. The diagnosis result may be a diagnosis result of a certain "patient", for example, the diagnosis result of a certain "patient" is a leg fracture, the diagnosis and treatment plan may be a list of medicines used by medical staff (for example, a doctor), a payment credential for the "patient" requiring an operation, a length of stay for the "patient" to stay in hospital, and the like.
The live image may be a live image of a "patient" or a live image of a medical staff, and the live image refers to a live image in a diagnosis and treatment stage, for example, a certain patient pays a fee at a payment window, and an image of the patient captured at the payment window by, for example, a camera is a live image.
For example, can be in the window department installation snapshot camera of paying fees, realize the people's face snapshot of using the medical insurance card to pay fees, can also install face recognition device in medical personnel's the room of diagnosing, realize the verification to doctor's identity and the verification to patient's identity, can also install the snapshot camera in nurse station or branch office's department, pay fees when the patient, carry out the face snapshot when handling in-hospital procedure etc., can also be in hospital corridor, in the ward, regional installation snapshot cameras such as ward gate, acquire the snapshot facial image of full period.
Step S102: and comparing the identities of the medical insurance participants according to the field images, and/or judging whether the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result, if the identity comparison result is abnormal and/or the diagnosis and treatment scheme belongs to the violation scheme, executing the step S103, and if the identity comparison result is not abnormal and the diagnosis and treatment scheme does not belong to the violation scheme, executing the step S104.
Step S103: and determining that medical insurance violation exists.
Step S104: determining that no medical insurance violation exists.
In an embodiment of this embodiment, when the medical insurance participant includes a medical staff and the clinic session is an outpatient payment session, the step of "comparing the identities of the medical insurance participant according to the live image" specifically includes the following steps S201 to S203:
step S201: whether the face image of the person who participates in the medical care is included in the face image related to the live image is judged, if the face image is included, the step S202 is executed, and if the face image is not included, the step S203 is executed.
Step S202: and judging that the identity comparison result is not abnormal.
Step S203: and continuously judging whether the number of the face images related to the insured visit personnel is smaller than a preset threshold value, if so, executing the step S204, and if not, executing the step S205.
Step S204: and judging that the identity comparison result is abnormal, and associating the live image with the visit and security personnel to serve as a new face image associated with the visit and security personnel.
Step S205: and judging that the identity comparison result is abnormal.
For example, when a certain person pays at a payment window, a live image of the person can be acquired through the camera, and then the live image is compared with a face image associated with the person participating in the medical care to judge whether the associated face image contains the person. For example, when the person a handles payment at the payment window for the person B belonging to the family, that is, the person B is the aforementioned security visit person, the live image of the person a may be captured at this time, and it is determined whether the person a is included in the face image associated with the person B, and if the person B is the person already associated with the person a is A, B, C, it may be determined that the identity comparison result is not abnormal, and if the person B is the person already associated with the person B is B, C, it may be determined that the person a is also associated with the person B, and if the person already associated with the medical insurance card is B, C, D, and the threshold of the number of associated persons is 3, it is determined that the identity comparison result is abnormal at this time. The threshold value is not a fixed value, and may be adjusted according to actual conditions.
By the method, the occurrence of the situation that the medical insurance card is falsely used can be reduced, the threshold value of the associated face image is set, the use experience of the patient is improved to a certain extent, the situation that the medical insurance card can only be held by the patient and the payment is carried out is avoided, and the problem that the patient cannot personally hold the medical insurance card to pay at the payment window under certain special conditions is considered.
In an embodiment of this embodiment, when the medical insurance participant includes a medical staff, the step of "comparing the identities of the medical insurance participant according to the live image" may include steps S1 to S6 shown in fig. 3:
step S1: matching the face according to the field image of the medical staff and the face image related to the medical staff; if the face matching is successful, go to step S2; if the face matching fails, the process goes to step S5.
Step S2: after detecting that medical staff generate the visit information aiming at the visit-keeping staff, judging whether to acquire a site image of the visit-keeping staff related to the visit information; if yes, go to step S3; if not, go to step S5.
Step S3: carrying out face matching according to the live images of the attendants and the face images related to the attendants; if the face matching fails, go to step S5; if the face matching is successful, go to step S4.
Step S4: judging whether the medical care personnel have the authority of generating the information of seeing a doctor; if not, the process goes to step S5, and if yes, the process goes to step S6.
Step S5: and judging that the identity comparison result is abnormal.
Step S6: and judging that the identity comparison result is not abnormal.
For example, when a doctor a is performing a diagnosis, first, a diagnosis system of a medical institution, for example, an account of the doctor a needs to be logged in, at this time, a live image of the doctor a can be recognized by the face recognition device, and when the live image is consistent with a face image of the doctor a reserved in the account, the system can be logged in to perform the diagnosis. For example, after doctor a generates the visit information, if doctor a records patient B in the visit information generated by doctor a, the live image of patient B can be acquired, if the live image of patient B cannot be acquired, it is determined that the identity comparison result is abnormal, if the acquired live image of patient and the face image of patient B do not match, it is determined that the identity comparison result is abnormal, and when the face image of patient B is acquired and the comparison result is the same person, it is determined that the identity comparison result is not abnormal.
The medical staff's service ability can also be documented, for example, if doctor A is a surgeon, then doctor A can be given a right to see information about the surgery. For example, if doctor a generates a visit message for patient B about the human nervous system and doctor a only has the right to generate a visit message for surgery, then it can be determined that there is an abnormality in the identity comparison result, and if doctor a generates a visit message for patient B about surgery, then it can be determined that there is no abnormality in the identity comparison result.
By the method, the occurrence of an impersonation medical action can be avoided, the false diagnosis and treatment of medical staff are also avoided, the information of seeing a doctor is generated under the condition that no patient or the patient is unmatched, and the service that the doctor exceeds the service capability range is avoided.
In an embodiment of this embodiment, when the medical insurance-participating subject includes a medical staff and the medical stage is an hospitalization/treatment stage, the step of "performing identity comparison on the medical insurance-participating subject according to the live image" specifically includes steps S401 to S404 shown in fig. 4:
step S401: the visit information of the visiting personnel is acquired to determine the hospitalization/treatment time of the visiting personnel.
Step S402: and judging whether the face images related to the personnel participating in the medical care are acquired within the hospitalization/treatment time and are represented as live images of the same personnel, if not, executing the step S403, and if so, executing the step S404.
Step S403: and judging that the identity comparison result is abnormal.
Step S404: and judging that the identity comparison result is not abnormal.
For example, if a certain piece of medical information records that a B patient participates in a medical treatment at doctor a in hospital XX at 10:00 at 1 month and 1 day in 2020, a live image of the XX hospital at 9:00 to 11:00 at 1 month and 1 day in 2020 can be acquired, for example, a camera at a doorway of a doctor clinic of the a doctor is used to acquire the live image, whether the live image of the B patient exists in the time period is determined, if so, it is determined that the identity comparison result is not abnormal, if not, it is determined that the identity comparison result is abnormal, it should be noted that the time period from 9:00 to 11:00 is only an example, and a value range of the determination time period is not limited, and a person skilled in the art can freely determine the determined time period according to actual situations or actual needs.
For another example, it is recorded in a certain piece of visit information that the patient B is hospitalized in the XX hospital for 15 days from 1/2020 to 1/15/2020, at this time, a live image from 1/2020 to 1/15/2020 can be acquired by a camera in a ward or in a corridor of the ward, and it is determined whether the live image of the patient B is acquired in the time period, if so, it is determined that the identity comparison result is not abnormal, and if not, it is determined that the identity comparison result is abnormal.
By the method, medical insurance violations such as false hospitalization and false treatment are avoided.
For example, the medicines used for the leg fracture are generally one or more of medicine 1, medicine 2, medicine 3, medicine 4, medicine 5, medicine 6, medicine 7 and medicine 8, and the medicines used for the diagnosis and treatment plan included in the visit information generated by doctor a for patient B include medicine 9, so that it can be determined that the diagnosis and treatment plan belongs to the violation plan corresponding to the diagnosis result. For example, the ratio of the drugs used for the leg fracture is 50% for drug 1, 30% for drug 2, and 20% for drug 3, and the drugs waiting for the diagnosis and treatment plan included in the visit information generated by doctor a for patient B are 80% for drug 1, 10% for drug 2, and 10% for drug 3, and it can be determined that the diagnosis and treatment plan belongs to the violation plan corresponding to the diagnosis result.
By the method, medical insurance violation conditions such as random medicine prescription of medical care personnel, mismatching of medicine prescription and diagnosis results and the like are avoided.
In an embodiment of this embodiment, the medical insurance violation may also be warned through steps S501 to S503 as shown in fig. 5:
step S501: and respectively determining the medical insurance violation types corresponding to the identity comparison result and the diagnosis and treatment scheme.
Step S502: and searching an alarm level corresponding to the medical insurance violation type in a preset alarm level library.
Step S503: and alarming according to the alarm level.
The medical insurance violation types may be various, for example, the imposition medical insurance card, imposition traveling medical service, false treatment, and the like in the above embodiment may be set, an alarm level library may be set to determine an alarm level corresponding to the medical insurance violation, for example, the alarm level is divided into 1, 2, 3, 4, and 5 levels, the imposition medical insurance card in an actual scene is set to 1 level, overtime hospitalization is set to 2 level, false hospitalization is set to 3 level, imposition traveling medical service is set to 4 level, and false treatment is set to 5 level, after the medical insurance violation type is determined, the alarm level may be determined in the alarm level library and an alarm may be performed, for example, the medical insurance violation type is determined to be the imposition medical insurance card, then a level 1 alarm may be performed, the alarm level may reduce the supervision pressure, and improve the supervision efficiency.
In an embodiment of the present embodiment, the step of "determining whether the diagnosis and treatment plan belongs to the violation plan corresponding to the diagnosis result" specifically includes steps S601 to S604 shown in fig. 6:
step S601: and acquiring violation scheme judgment conditions corresponding to the diagnosis result from a preset rule base.
Step S602: and judging whether the diagnosis and treatment scheme meets the violation scheme judgment condition, if so, executing the step S603, and if not, executing the step S604.
Step S603: and judging that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result.
Step S604: and judging that the diagnosis and treatment scheme does not belong to the violation scheme corresponding to the diagnosis result.
For example, if the preset rule base records that the hospitalization time of the leg fracture is 30 days, and the violation scheme is that the hospitalization time is greater than 30 days, it can be determined whether the hospitalization time in the diagnosis and treatment scheme is greater than 30 days, and if so, it is determined that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result.
For another example, the preset rule base records that the medication names of the leg fracture may include medicine 1, medicine 2, medicine 3, medicine 4, and medicine 5, and if other medicines occur, the rule base is an illegal scheme, and then it may be determined whether the medication names of the diagnosis and treatment plan of the leg fracture include other medicines other than medicine 1, medicine 2, medicine 3, medicine 4, and medicine 5, and if so, it may be determined that the diagnosis and treatment plan belongs to the illegal scheme corresponding to the diagnosis result.
In an embodiment of this embodiment, the violation scheme determination condition may also be corrected through steps S701 to S703 as shown in fig. 7:
step S701: after the diagnosis and treatment scheme is judged to belong to the violation scheme, whether a misjudgment correction instruction for the diagnosis and treatment scheme is received or not is judged, if yes, step S702 is executed, and if not, step S703 is executed.
Step S702: adjusting the diagnosis and treatment scheme to be a non-violation scheme according to the misjudgment correction instruction, and correcting a violation scheme judgment condition according to the diagnosis and treatment scheme;
step S703: and determining that medical insurance violation exists and giving an alarm.
If the judgment condition of the violation scheme in the preset rule base is not fixed, for example, the hospitalization time of the leg fracture is 30 days, and the hospitalization time of the diagnosis and treatment scheme of the patient B is 35 days, the violation scheme is judged, after the misjudgment correction instruction for the diagnosis and treatment scheme is received, the diagnosis and treatment scheme can be manually checked, after the manual check is determined to be a non-violation scheme, the scheme can be adjusted to be a non-violation scheme, and the judgment condition of the violation scheme is corrected, for example, the diagnosis and treatment scheme is used as a sample, the hospitalization time due to the leg fracture is recalculated, and if the judgment condition of the violation scheme can be corrected to be 31 days after the calculation, the next hospitalization time with the leg fracture is 35 days, the violation scheme can be judged, and after the misjudgment correction instruction is received, the judgment condition of the violation scheme can be corrected again, when there are enough misjudgment cases, the judgment condition of the violation scheme can be corrected to be closest to the hospitalization time of the real leg fracture.
In one embodiment of this embodiment, when the medical insurance-participating subject includes an insurance visit staff and the visit stage is an in-patient/treatment stage, the violation plan determination condition may include:
the real hospitalization duration of the nursing personnel is longer than the hospitalization duration corresponding to the preset diagnosis result;
the real hospitalization times of the nursing personnel in the preset time length are larger than the hospitalization times corresponding to the preset diagnosis result.
Assuming that the hospitalization time of the leg fracture is generally 30 days, and the actual hospitalization time of the patient B is 35 days, it can be determined that the diagnosis and treatment plan belongs to the violation plan corresponding to the diagnosis result.
For example, if the hospitalization mode of leg fracture is generally 2 hospitalization times within 3 months, each hospitalization time is 20 days, while the actual hospitalization mode of B patient is 6 hospitalization times within three months, each hospitalization time is 7 days, it can be determined that the diagnosis and treatment plan belongs to the violation plan corresponding to the diagnosis result.
By the method, medical insurance violations such as overtime hospitalization and hospitalization decomposition are avoided.
In an embodiment of this embodiment, the medical insurance participation objects may include medical staff, medical staff and medical institutions, and the medical insurance violation monitoring method may further include:
and respectively establishing a medical insurance monitoring file for each medical insurance participating object.
The medical insurance monitoring files of the medical insurance visitors at least comprise identity information of the medical insurance visitors, face images related to the medical insurance visitors, the medical time, the medical place, medical staff and medical information during the medical treatment.
The medical insurance monitoring file of the medical staff at least comprises identity information of the medical staff, face images related to the medical staff, a medical institution, a diagnosis and treatment range, diagnosis and treatment time, a diagnosis and treatment object and diagnosis and treatment information.
The medical insurance monitoring file of the medical institution at least comprises medical insurance monitoring files of each medical staff and each medical staff in the medical institution.
Medical insurance monitoring files can be established for medical institutions, medical personnel and medical personnel participating in insurance and visiting patients, and data bases are provided for other use scenes.
In an embodiment of the present invention, after determining that the medical insurance participant has medical insurance violation, the warning information that the medical insurance participant has medical insurance violation is uploaded to a preset credit evaluation system.
The warning information at least comprises the medical insurance violation type of the medical insurance participating object.
The medical insurance violation can be uploaded to a credit evaluation system, such as a credit investigation system, and when the medical insurance violation affects personal credit investigation, the medical insurance violation can be avoided to a great extent. The medical institution, the medical staff and the personnel attending the medical insurance are prompted to follow the medical insurance regulation.
In an embodiment of this embodiment, the method for monitoring medical insurance violation may further include:
and responding to the complaint instruction aiming at the alarm information, sending a complaint request of the illegal action of the medical insurance to a preset medical insurance supervision platform, and receiving response information fed back by the medical insurance supervision platform according to the complaint request of the illegal action of the medical insurance.
After the medical insurance violation occurs, a complaint request can be sent to the medical insurance monitoring platform, for example, diagnosis and treatment information generated by a certain medical worker is judged to be a violation scheme, the medical worker can submit related complaint certification materials to the medical insurance monitoring platform to apply for cancelling judgment of the medical insurance violation.
Based on the steps S101 to S104, the whole process of monitoring can be carried out on each clinic stage, so that medical insurance violation behaviors are reduced, and the supervision efficiency of the medical insurance violation behaviors is improved.
It should be noted that, although the foregoing embodiments describe each step in a specific sequence, those skilled in the art will understand that, in order to achieve the effect of the present invention, different steps do not necessarily need to be executed in such a sequence, and they may be executed simultaneously (in parallel) or in other sequences, and these changes are all within the protection scope of the present invention.
Further, the invention also provides a device for monitoring medical insurance violation.
Referring to fig. 8, fig. 8 is a main structural block diagram of a medical insurance violation monitoring apparatus according to an embodiment of the present invention. As shown in fig. 8, the medical insurance violation monitoring apparatus in the embodiment of the present invention mainly includes a data acquisition module 81, a violation verification module 82, and a medical insurance violation determination module 83. In some embodiments, one or more of the data collection module 81, the violation verification module 82, and the medical insurance violation determination module 83 may be combined together into one module. In some embodiments, the data acquisition module 81 may be configured to acquire, for each session, a live image of the subject participating in the medical care during the session and the generated medical care information, wherein the medical care information includes a diagnosis result and a treatment plan. The violation verification module 82 may be configured to compare identities of the medical insurance participants according to the live images, and/or determine whether the diagnosis and treatment plan belongs to a violation plan corresponding to the diagnosis result. The medical insurance violation determination module 83 may be configured to determine that a medical insurance violation exists if the identity comparison result is abnormal and/or the diagnosis and treatment plan is determined to belong to a violation plan. In one embodiment, the description of the specific implementation function may refer to the description of step S101 to step S104.
In one embodiment, the medical insurance violation determination module is further configured to perform the following operations to alert the medical insurance violation:
respectively determining medical insurance violation types corresponding to the identity comparison result and the diagnosis and treatment scheme;
searching an alarm level corresponding to the medical insurance violation type in a preset alarm level library;
and alarming according to the alarm level. In one embodiment, the description of the specific implementation function may refer to the description of step S501 to step S503.
And/or the like and/or,
the violation verification module is further configured to perform the following operations:
and acquiring violation scheme judgment conditions corresponding to the diagnosis result from a preset rule base.
And judging whether the diagnosis and treatment scheme meets the rule-breaking scheme judgment condition.
If so, judging that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result; if not, judging that the diagnosis and treatment scheme does not belong to the violation scheme corresponding to the diagnosis result. In one embodiment, the description of the specific implementation function may refer to the descriptions of step S601 to step S604.
In one embodiment, the violation verification module is further configured to perform the following operations:
and after judging that the diagnosis and treatment scheme belongs to the violation scheme, judging whether a misjudgment correction instruction aiming at the diagnosis and treatment scheme is received.
If so, adjusting the diagnosis and treatment scheme to be a non-violation scheme according to the misjudgment correction instruction, and correcting the violation scheme judgment condition according to the diagnosis and treatment scheme. In one embodiment, the description of the specific implementation function may refer to the descriptions of step S701 to step S703.
And/or the like and/or,
when the medical insurance-participating subject includes an insurance-attending staff and the visiting stage is an inpatient/treatment stage, the violation plan determination condition may include:
the real hospitalization duration of the nursing personnel is longer than the hospitalization duration corresponding to the preset diagnosis result.
The real hospitalization times of the nursing personnel in the preset time length are larger than the hospitalization times corresponding to the preset diagnosis result.
In one embodiment, when the subject of medical insurance participation comprises an insurance visit and the visit stage is an outpatient payment stage, the violation verification module is configured to perform the following operations:
and judging whether the face images related to the personnel participating in the medical treatment contain the face images which are expressed as the same personnel as the live images.
When the identity comparison result is contained, the identity comparison result is judged to have no abnormity.
And when the face images are not included, continuously judging whether the number of the face images related to the attendants is less than a preset threshold value.
And if so, judging that the identity comparison result is abnormal, and associating the field image with the visit and security personnel to serve as a new face image associated with the visit and security personnel.
If not, judging that the identity comparison result is abnormal. In one embodiment, the description of the specific implementation function may refer to the description of step S201 to step S205.
And/or the like and/or,
when the medical insurance participant comprises a medical worker, the violation verification module is configured to:
step S1: matching the face according to the field image of the medical staff and the face image related to the medical staff; if the face matching is successful, go to step S2; and if the face matching fails, judging that the identity comparison result is abnormal.
Step S2: after detecting that medical staff generate the visit information aiming at the visit-keeping staff, judging whether to acquire a site image of the visit-keeping staff related to the visit information; if yes, go to step S3; if not, judging that the identity comparison result is abnormal.
Step S3: carrying out face matching according to the live images of the attendants and the face images related to the attendants; if the face matching fails, judging that the identity comparison result is abnormal; if the face matching is successful, go to step S4.
Step S4: judging whether the medical care personnel have the authority of generating the information of seeing a doctor; if not, judging that the identity comparison result is abnormal. In one embodiment, the detailed implementation functions may be described in reference to steps S1 to S6.
And/or the like and/or,
when the medical insurance participant comprises an insurance visit and the visit stage is an hospitalization/treatment stage, the violation verification module is configured to perform the following operations:
the visit information of the visiting personnel is acquired to determine the hospitalization/treatment time of the visiting personnel.
It is determined whether the facial image associated with the attending clinician was acquired during the hospitalization/treatment period as a live image of the same person.
If not, judging that the identity comparison result is abnormal. In one embodiment, the description of the specific implementation function may refer to the descriptions of step S401 to step S404.
In one embodiment, the medical insurance participants may include medical personnel, medical staff and medical institutions, and the medical insurance violation monitoring apparatus may further include a monitoring profile establishing module configured to establish a medical insurance monitoring profile for each medical insurance participant, respectively.
The medical insurance monitoring files of the medical insurance visitors at least comprise identity information of the medical insurance visitors, face images related to the medical insurance visitors, the medical time, the medical place, medical staff and medical information during the medical treatment.
The medical insurance monitoring file of the medical staff at least comprises identity information of the medical staff, face images related to the medical staff, a medical institution, a diagnosis and treatment range, diagnosis and treatment time, a diagnosis and treatment object and diagnosis and treatment information.
The medical insurance monitoring file of the medical institution at least comprises medical insurance monitoring files of each medical staff and each medical staff in the medical institution.
In one embodiment, the medical insurance violation monitoring device may further include a warning information uploading module, where the warning information uploading module is configured to upload warning information indicating that the medical insurance participant violates the medical insurance violation to a preset credit evaluation system after determining that the medical insurance participant violates the medical insurance violation.
The warning information at least comprises the medical insurance violation type of the medical insurance participating object.
And/or the like and/or,
the medical insurance violation monitoring device can further comprise a complaint module, wherein the complaint module is configured to respond to complaint instructions aiming at the alarm information, send complaint requests of medical insurance violation behaviors to a preset medical insurance monitoring platform, and receive response information fed back by the medical insurance monitoring platform according to the complaint requests of medical insurance violation behaviors.
The technical principles, the solved technical problems and the generated technical effects of the medical insurance violation monitoring device shown in fig. 1 are similar to each other, and it can be clearly understood by those skilled in the art that, for convenience and simplicity of description, the specific working process and the related description of the medical insurance violation monitoring device may refer to the contents described in the embodiment of the medical insurance violation monitoring method, and are not described herein again.
In another embodiment of this embodiment, there is further provided a medical insurance fund monitoring system, including:
and the sensing layer is configured to acquire a field image and acquire the visit information of the medical personnel involved in the medical treatment through the medical insurance information system and the hospital information management system, wherein the visit information can comprise payment, visit, medicine purchase and hospitalization information. In one embodiment, the specific implementation is similar to the above step S101, and for brevity of description, the detailed description is omitted here.
And the platform layer is configured to identify the field image, compare identities, or analyze the information of the doctor to determine whether the violation scheme is the violation scheme, so as to determine medical insurance violation behaviors. In one embodiment, the specific implementation is similar to the above step S102, and for brevity of description, the detailed description is omitted here.
And the data application layer is configured to alarm and display medical insurance violation behaviors. In one embodiment, the specific implementation is similar to the above steps S103 to S104, and for brevity, the detailed description is omitted here.
It will be understood by those skilled in the art that all or part of the flow of the method according to the above-described embodiment may be implemented by a computer program, which may be stored in a computer-readable storage medium and used to implement the steps of the above-described embodiments of the method when the computer program is executed by a processor. Wherein the computer program comprises computer program code, which may be in the form of source code, object code, an executable file or some intermediate form, etc. The computer-readable medium may include: any entity or device capable of carrying said computer program code, media, usb disk, removable hard disk, magnetic diskette, optical disk, computer memory, read-only memory, random access memory, electrical carrier wave signals, telecommunication signals, software distribution media, etc. It should be noted that the computer readable medium may contain content that is subject to appropriate increase or decrease as required by legislation and patent practice in jurisdictions, for example, in some jurisdictions, computer readable media does not include electrical carrier signals and telecommunications signals as is required by legislation and patent practice.
Furthermore, the invention also provides a control device. In an embodiment of the control device according to the present invention, the control device comprises a processor and a storage device, the storage device may be configured to store a program for executing the medical insurance violation monitoring method of the above-mentioned method embodiment, and the processor may be configured to execute a program in the storage device, the program including but not limited to a program for executing the medical insurance violation monitoring method of the above-mentioned method embodiment. For convenience of explanation, only the parts related to the embodiments of the present invention are shown, and details of the specific techniques are not disclosed. The control device may be a control device apparatus formed including various electronic apparatuses.
Further, the invention also provides a computer readable storage medium. In one computer-readable storage medium embodiment according to the present invention, the computer-readable storage medium may be configured to store a program for executing the medical insurance violation monitoring method of the above-described method embodiment, and the program may be loaded and executed by the processor to implement the medical insurance violation monitoring method. For convenience of explanation, only the parts related to the embodiments of the present invention are shown, and details of the specific techniques are not disclosed. The computer readable storage medium may be a storage device formed by including various electronic devices, and optionally, the computer readable storage medium is a non-transitory computer readable storage medium in the embodiment of the present invention.
Further, it should be understood that, since the configuration of each module is only for explaining the functional units of the apparatus of the present invention, the corresponding physical devices of the modules may be the processor itself, or a part of software, a part of hardware, or a part of a combination of software and hardware in the processor. Thus, the number of individual modules in the figures is merely illustrative.
Those skilled in the art will appreciate that the various modules in the apparatus may be adaptively split or combined. Such splitting or combining of specific modules does not cause the technical solutions to deviate from the principle of the present invention, and therefore, the technical solutions after splitting or combining will fall within the protection scope of the present invention.
So far, the technical solutions of the present invention have been described in connection with the preferred embodiments shown in the drawings, but it is easily understood by those skilled in the art that the scope of the present invention is obviously not limited to these specific embodiments. Equivalent changes or substitutions of related technical features can be made by those skilled in the art without departing from the principle of the invention, and the technical scheme after the changes or substitutions can fall into the protection scope of the invention.
Claims (12)
1. A medical insurance violation monitoring method is characterized by comprising the following steps:
acquiring a site image of a medical insurance participant in each clinic stage and generated clinic information, wherein the clinic information comprises a diagnosis result and a diagnosis and treatment scheme;
comparing the identities of the medical insurance participants according to the field image, and/or,
judging whether the diagnosis and treatment scheme belongs to an illegal scheme corresponding to the diagnosis result;
and if the identity comparison result is abnormal and/or the diagnosis and treatment scheme is judged to belong to the illegal scheme, determining that medical insurance illegal behaviors exist.
2. The medical insurance violation monitoring method of claim 1, further comprising alerting the medical insurance violation by:
respectively determining medical insurance violation types corresponding to the identity comparison result and the diagnosis and treatment scheme;
searching an alarm level corresponding to the medical insurance violation type in a preset alarm level library;
alarming according to the alarm level;
and/or the like and/or,
the step of determining whether the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result specifically includes:
acquiring violation scheme judgment conditions corresponding to the diagnosis result from a preset rule base;
judging whether the diagnosis and treatment scheme meets the rule-breaking scheme judgment condition or not;
if so, judging that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result; if not, judging that the diagnosis and treatment scheme does not belong to the violation scheme corresponding to the diagnosis result.
3. The medical insurance violation monitoring method according to claim 2, further comprising correcting the violation scheme determination condition by:
after judging that the diagnosis and treatment scheme belongs to the illegal scheme, judging whether a misjudgment correction instruction aiming at the diagnosis and treatment scheme is received or not;
if so, adjusting the diagnosis and treatment scheme to be a non-violation scheme according to the misjudgment correction instruction, and correcting the violation scheme judgment condition according to the diagnosis and treatment scheme;
and/or the like and/or,
when the medical insurance participation object comprises a medical insurance visit staff and the visit stage is an inpatient/treatment stage, the violation scheme judgment condition comprises the following steps:
the real hospitalization duration of the nursing personnel is longer than the preset hospitalization duration corresponding to the diagnosis result;
the real hospitalization times of the nursing personnel in the preset time length are larger than the preset hospitalization times corresponding to the diagnosis result.
4. The medical insurance violation monitoring method according to claim 1, wherein when the medical insurance participant comprises an insurance visit staff and the visit stage is an outpatient payment stage, the step of performing identity comparison on the medical insurance participant according to the live image specifically comprises:
judging whether the face images related to the personnel participating in the medical care already contain the face images which are expressed as the same personnel as the live images;
when the identity comparison result is contained, judging that the identity comparison result is not abnormal;
when the face images are not included, continuously judging whether the number of the face images related to the insured visit personnel is smaller than a preset threshold value;
if so, judging that the identity comparison result is abnormal, and associating the field image with the visit personnel as a new face image associated with the visit personnel;
if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participating object comprises medical staff, the step of comparing the identities of the medical insurance participating object according to the field image specifically comprises the following steps:
step S1: matching the face according to the field image of the medical staff and the face image related to the medical staff; if the face matching is successful, go to step S2; if the face matching fails, judging that the identity comparison result is abnormal;
step S2: judging whether a site image of a medical staff attending a doctor related to the doctor information is acquired or not after the doctor information is detected to be generated by the medical staff aiming at the doctor attending the doctor; if yes, go to step S3; if not, judging that the identity comparison result is abnormal;
step S3: carrying out face matching according to the live images of the attendants and the face images related to the attendants; if the face matching fails, judging that the identity comparison result is abnormal; if the face matching is successful, go to step S4;
step S4: judging whether the medical personnel has the authority of generating the visit information; if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participation object comprises a medical insurance visit staff and the visit stage is an hospitalization/treatment stage, the step of comparing the identities of the medical insurance participation object according to the live image specifically comprises the following steps:
acquiring the visit information of the visit attendants to determine the hospitalization/treatment time of the visit attendants;
judging whether the face images associated with the medical personnel are acquired and represented as the on-site images of the same personnel within the hospitalization/treatment time;
if not, judging that the identity comparison result is abnormal.
5. The medical insurance violation monitoring method of claim 1, wherein the medical insurance participating objects include medical attendants, medical personnel, and medical institutions, the method further comprising:
respectively establishing a medical insurance monitoring file for each medical insurance participating object;
the medical insurance monitoring files of the medical insurance visitors at least comprise identity information of the medical insurance visitors, face images related to the medical insurance visitors, the medical time, the medical place, medical staff and medical information during the medical treatment;
the medical insurance monitoring file of the medical staff at least comprises identity information of the medical staff, a face image related to the medical staff, a medical institution, a diagnosis and treatment range, diagnosis and treatment time, a diagnosis and treatment object and diagnosis and treatment information;
the medical insurance monitoring file of the medical institution at least comprises medical insurance monitoring files of each medical staff and each medical staff in the medical institution.
6. The medical insurance violation monitoring method according to claim 1, wherein after determining that the medical insurance participant has the medical insurance violation, the medical insurance participant uploads warning information of the medical insurance violation to a preset credit evaluation system;
the warning information at least comprises the medical insurance violation type of the medical insurance participant;
and/or the like and/or,
the method further comprises the following steps:
responding to a complaint instruction aiming at the alarm information, sending a complaint request of the illegal action of the medical insurance to a preset medical insurance supervision platform, and receiving response information fed back by the medical insurance supervision platform according to the complaint request of the illegal action of the medical insurance.
7. A medical insurance violation monitoring device, the device comprising:
a data acquisition module configured to acquire, for each visit stage, a live image of a medical insurance participant in the visit stage and generated visit information, wherein the visit information includes a diagnosis result and a diagnosis and treatment plan;
a violation verification module configured to compare identities of the medical insurance participants according to the live image, and/or,
judging whether the diagnosis and treatment scheme belongs to an illegal scheme corresponding to the diagnosis result;
and the medical insurance violation determining module is configured to determine that medical insurance violation exists if the identity comparison result is abnormal and/or the diagnosis and treatment scheme is judged to belong to a violation scheme.
8. The medical insurance violation monitoring device according to claim 7, wherein the medical insurance violation determining module is further configured to perform the following operations to alert the medical insurance violation:
respectively determining medical insurance violation types corresponding to the identity comparison result and the diagnosis and treatment scheme;
searching an alarm level corresponding to the medical insurance violation type in a preset alarm level library;
alarming according to the alarm level;
and/or the like and/or,
the violation verification module is further configured to perform the following:
acquiring violation scheme judgment conditions corresponding to the diagnosis result from a preset rule base;
judging whether the diagnosis and treatment scheme meets the rule-breaking scheme judgment condition or not;
if so, judging that the diagnosis and treatment scheme belongs to the violation scheme corresponding to the diagnosis result; if not, judging that the diagnosis and treatment scheme does not belong to the violation scheme corresponding to the diagnosis result.
9. The medical insurance violation monitoring device according to claim 8, wherein the violation verification module is further configured to:
after judging that the diagnosis and treatment scheme belongs to the illegal scheme, judging whether a misjudgment correction instruction aiming at the diagnosis and treatment scheme is received or not;
if so, adjusting the diagnosis and treatment scheme to be a non-violation scheme according to the misjudgment correction instruction, and correcting the violation scheme judgment condition according to the diagnosis and treatment scheme;
and/or the like and/or,
when the medical insurance participation object comprises a medical insurance visit staff and the visit stage is an inpatient/treatment stage, the violation scheme judgment condition comprises the following steps:
the real hospitalization duration of the nursing personnel is longer than the preset hospitalization duration corresponding to the diagnosis result;
the real hospitalization times of the nursing personnel in the preset time length are larger than the preset hospitalization times corresponding to the diagnosis result.
10. The medical insurance violation monitoring device according to claim 7, wherein when the medical insurance participant comprises an insurance visit and the visit stage is an outpatient payment stage, the violation verification module is configured to:
judging whether the face images related to the personnel participating in the medical care already contain the face images which are expressed as the same personnel as the live images;
when the identity comparison result is contained, judging that the identity comparison result is not abnormal;
when the face images are not included, continuously judging whether the number of the face images related to the insured visit personnel is smaller than a preset threshold value;
if so, judging that the identity comparison result is abnormal, and associating the field image with the visit personnel as a new face image associated with the visit personnel;
if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participant comprises a healthcare worker, the violation verification module is configured to:
step S1: matching the face according to the field image of the medical staff and the face image related to the medical staff; if the face matching is successful, go to step S2; if the face matching fails, judging that the identity comparison result is abnormal;
step S2: judging whether a site image of a medical staff attending a doctor related to the doctor information is acquired or not after the doctor information is detected to be generated by the medical staff aiming at the doctor attending the doctor; if yes, go to step S3; if not, judging that the identity comparison result is abnormal;
step S3: carrying out face matching according to the live images of the attendants and the face images related to the attendants; if the face matching fails, judging that the identity comparison result is abnormal; if the face matching is successful, go to step S4;
step S4: judging whether the medical personnel has the authority of generating the visit information; if not, judging that the identity comparison result is abnormal;
and/or the like and/or,
when the medical insurance participant comprises an insurance visit and the visit stage is an hospitalization/treatment stage, the violation verification module is configured to:
acquiring the visit information of the visit attendants to determine the hospitalization/treatment time of the visit attendants;
judging whether the face images associated with the medical personnel are acquired and represented as the on-site images of the same personnel within the hospitalization/treatment time;
if not, judging that the identity comparison result is abnormal.
11. A control apparatus comprising a processor and a storage device adapted to store a plurality of program codes, wherein the program codes are adapted to be loaded and run by the processor to perform the method of medical insurance violation monitoring of any of claims 1-6.
12. A computer readable storage medium having a plurality of program codes stored therein, wherein the program codes are adapted to be loaded and executed by a processor to perform the method for medical insurance violation monitoring of any of claims 1-6.
Priority Applications (1)
| Application Number | Priority Date | Filing Date | Title |
|---|---|---|---|
| CN202111032701.XA CN113780792A (en) | 2021-09-03 | 2021-09-03 | Medical insurance violation monitoring method and device and computer readable storage medium |
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| CN114493894A (en) * | 2021-12-17 | 2022-05-13 | 武汉金豆医疗数据科技有限公司 | Method for monitoring medical behaviors by using medical insurance audit rule model |
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