CN114723420A - Medical insurance, business and insurance integrated auditing method and device, electronic equipment and storage medium - Google Patents
Medical insurance, business and insurance integrated auditing method and device, electronic equipment and storage medium Download PDFInfo
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Abstract
The utility model discloses a medical insurance, merchant and insurance integrated auditing method and device, electronic equipment and storage medium, and relates to the technical field of data processing.
Description
Technical Field
The disclosure relates to the technical field of data processing, and in particular to a medical insurance, merchant and security integration auditing method and device, electronic equipment and a storage medium.
Background
With the continuous deepening of the advancing pace of the state to the major health industry, the social medical care guarantee can not meet the basic requirements of patients, the willingness of people to purchase the commercial health insurance is also enhanced, and under the condition of purchasing the commercial health insurance, the cost sharing mode of the hospitalization cost of the patients is medical insurance fund reimbursement, commercial health insurance reimbursement and self-payment of the patients.
At present, the business health insurance reimbursement claim part of hospitalization cost needs to be carried out through paper materials, such as paper materials of an insured identity certificate copy, a medical record copy covered hospital seal, a medical expense receipt original, a detail original of hospitalization medical charging items, a medical manual, a prescription, an inspection sheet, a laboratory test sheet and the like, a discharge summary, a social insurance reimbursement division sheet and the like, and after the paper materials are submitted, the corresponding cost reimbursement is executed after manual auditing.
As the examination and verification of the commercial health insurance reimbursement claim requires that the patient provides various paper materials, the examination and verification personnel is required to carry out examination and verification manually according to the submitted various paper materials; the reimbursement claim settlement mode not only needs manual collection of a large amount of complicated paper materials, but also depends on manual auditing, so that the conventional flow of business health insurance reimbursement occupies too much labor, a large amount of labor and time cost are wasted, and the auditing efficiency is further reduced.
Disclosure of Invention
The disclosure provides a medical insurance, merchant and security integration auditing method and device, electronic equipment and a storage medium. The method mainly aims to solve the problems that the existing business health insurance reimbursement process occupies too much labor, wastes a large amount of labor and time cost, and further reduces the auditing efficiency.
According to a first aspect of the present disclosure, there is provided an auditing method for medical insurance, merchant insurance integration, wherein the method includes:
acquiring diagnosis and treatment detail data to be checked, wherein the diagnosis and treatment detail data to be checked comprises user identity information and diagnosis and treatment data to be checked;
determining whether to participate in target insurance according to the user identity information, wherein the target insurance comprises at least one of medical insurance and business health insurance;
inputting the diagnostic data to be audited into a reimbursement audit engine corresponding to the target insurance;
inquiring a code library corresponding to the target insurance based on the reimbursement auditing engine, wherein the code library is a code of the name of the diagnosis and treatment data under the associated insurance participation, and one insurance participation is associated with one code library;
and auditing the diagnosis and treatment data to be audited according to the query result and a preset reimbursement knowledge base.
Optionally, when the target insurance is medical insurance and business health insurance;
the inputting the diagnostic data to be audited into the reimbursement audit engine corresponding to the target insurance comprises:
inputting the diagnostic data to be audited into a first reimbursement audit engine corresponding to the medical insurance;
the querying, based on the reimbursement auditing engine, the code library corresponding to the target insurance comprises:
inquiring a first code library corresponding to the medical insurance based on the first reimbursement auditing engine;
the examination of the diagnosis and treatment data to be examined according to the query result and a preset reimbursement knowledge base comprises the following steps:
examining and verifying the diagnosis and treatment data to be examined according to the query result and a first preset reimbursement knowledge base;
the inputting the diagnostic data to be audited into the reimbursement audit engine corresponding to the target insurance comprises:
inputting the diagnostic data to be audited into a second reimbursement audit engine corresponding to the commercial health insurance;
the querying, based on the reimbursement auditing engine, the code library corresponding to the target insurance comprises:
querying a second code library corresponding to the business health insurance based on the second reimbursement auditing engine;
the examination of the diagnosis and treatment data to be examined according to the query result and a preset reimbursement knowledge base comprises the following steps:
and auditing the diagnosis and treatment data to be audited according to the query result and a second preset reimbursement knowledge base.
Optionally, after the examination of the diagnosis and treatment data to be examined is performed according to the query result and the first preset reimbursement knowledge base, the method further includes:
inputting the diagnostic data to be audited into a third reimbursement audit engine;
and auditing the medical diagnosis behaviors in the diagnosis and treatment data to be audited based on the third reimbursement auditing engine and the first preset reimbursement knowledge base.
Optionally, the auditing the diagnosis and treatment data to be audited according to the query result and the first preset reimbursement knowledge base includes:
marking the diagnosis and treatment data to be examined which do not accord with the reimbursement policy of the overall planning area, and reminding the reexamination of the diagnosis and treatment data to be examined which do not accord with the reimbursement policy of the overall planning area.
Optionally, the auditing the diagnosis and treatment data to be audited according to the query result and a second preset reimbursement knowledge base includes:
and marking the to-be-audited diagnostic data which do not accord with the business health insurance, and suspending reimbursement of the business health insurance on the to-be-audited diagnostic data.
Optionally, the method further includes:
acquiring data to be coded for medical insurance supervision and audit in the overall area;
and coding the data to be coded to generate the first coding library.
Optionally, the method further includes:
obtaining all commercial health products in each commercial health insurance factory;
analyzing to obtain reimbursement terms in all commercial health products;
and coding the reimbursement clauses to generate the second code library.
According to a second aspect of the present disclosure, there is provided an integrated auditing device for medical insurance, business insurance, comprising:
the system comprises a first acquisition unit, a second acquisition unit and a processing unit, wherein the first acquisition unit is used for acquiring diagnosis and treatment detail data to be examined, and the diagnosis and treatment detail data to be examined comprise user identity information and diagnosis and treatment data to be examined;
the determining unit is used for determining whether to participate in target insurance according to the user identity information, wherein the target insurance comprises at least one of medical insurance and business health insurance;
the first input unit is used for inputting the diagnostic data to be audited into a reimbursement audit engine corresponding to the target insurance;
the query unit is used for querying a code library corresponding to the target insurance based on the reimbursement audit engine, wherein the code library is a code of the name of the diagnosis and treatment data under the associated insurance participation, and one insurance participation is associated with one code library;
and the first auditing unit is used for auditing the diagnosis and treatment data to be audited according to the query result and a preset reimbursement knowledge base.
Optionally, when the target insurance is medical insurance and business health insurance;
the first input unit is further used for inputting the diagnostic data to be audited into a first reimbursement audit engine corresponding to the medical insurance;
the query unit is further configured to query a first code library corresponding to the medical insurance based on the first reimbursement auditing engine;
the first auditing unit is also used for auditing the diagnosis and treatment data to be audited according to the query result and a first preset reimbursement knowledge base;
the first input unit is further used for inputting the diagnostic data to be audited into a second reimbursement audit engine corresponding to the commercial health insurance;
the query unit is further configured to query a second code library corresponding to the business health insurance based on the second reimbursement auditing engine;
and the first auditing unit is also used for auditing the diagnosis and treatment data to be audited according to the query result and a second preset reimbursement knowledge base.
Optionally, after the first reviewing unit, the apparatus further includes:
the second input unit is used for inputting the diagnostic data to be audited into a third reimbursement audit engine;
and the second auditing unit is used for auditing the medical diagnosis behaviors in the diagnosis and treatment data to be audited based on the third reimbursement auditing engine and the first preset reimbursement knowledge base.
Optionally, the first auditing unit is further configured to label data that does not comply with the reimbursement policy of the orchestration area, and remind the reviewing of the to-be-reviewed medical data that does not comply with the reimbursement policy of the orchestration area.
Optionally, the first auditing unit is further configured to label the to-be-audited diagnostic data that does not meet the business health insurance, and suspend reimbursement of the business health insurance for the to-be-audited diagnostic data.
Optionally, the apparatus further comprises:
the second acquisition unit is used for acquiring data to be coded for medical insurance supervision and audit in the overall area;
and the first coding unit is used for coding the data to be coded to generate the first coding library.
Optionally, the apparatus further comprises:
a third acquiring unit for acquiring all the commercial health products in each commercial health insurance factory;
the analysis unit is used for analyzing and obtaining reimbursement terms in all the commercial health products;
and the second coding unit is used for coding the reimbursement clauses to generate the second code library.
According to a third aspect of the present disclosure, there is provided an electronic device comprising:
at least one processor; and
a memory communicatively coupled to the at least one processor; wherein the content of the first and second substances,
the memory stores instructions executable by the at least one processor to enable the at least one processor to perform the method of the first aspect.
According to a fourth aspect of the present disclosure, there is provided a non-transitory computer readable storage medium having stored thereon computer instructions for causing the computer to perform the method of the aforementioned first aspect.
According to a fifth aspect of the present disclosure, a computer program product is provided, comprising a computer program which, when executed by a processor, implements the method as set forth in the preceding first aspect.
The technical scheme of the medical insurance, merchant insurance and security integration auditing method, device, electronic equipment and storage medium provided by the disclosure includes: the method comprises the steps of obtaining diagnosis and treatment detail data to be audited, wherein the diagnosis and treatment detail data to be audited comprise user identity information and diagnosis and treatment data to be audited, determining whether to participate in target insurance or not according to the user identity information, wherein the target insurance comprises at least one of medical insurance and commercial health insurance, inputting the diagnosis and treatment data to be audited into an reimbursement auditing engine corresponding to the target insurance, inquiring a code base corresponding to the target insurance based on the reimbursement auditing engine, wherein the code base is a code of the name of the diagnosis and treatment data under the associated reimbursement insurance, one kind of the reimbursement insurance is associated with one code base, and auditing the diagnosis and treatment data to be audited according to an inquiry result and a preset reimbursement knowledge base. Compared with the prior art, the embodiment of the application finishes the examination of the medical insurance and/or the commercial health insurance of the user in the examination system integrating the medical insurance, the business insurance and the insurance after the participation type of the user is confirmed by acquiring the medical detail data to be examined of the user, does not need to rely on manpower to examine a large amount of complicated paper materials, saves labor and time cost, and greatly improves the efficiency of the examination of the commercial health insurance.
It should be understood that the statements in this section do not necessarily identify key or critical features of the embodiments of the present application, nor do they limit the scope of the present application. Other features of the present application will become apparent from the following description.
Drawings
The drawings are included to provide a better understanding of the present solution and are not to be construed as limiting the present disclosure. Wherein:
fig. 1 is a schematic flow chart of an auditing method for medical insurance, merchant insurance integration provided in an embodiment of the present disclosure;
FIG. 2 is a schematic flow chart diagram illustrating a method for a user to participate in an audit of both medical insurance and business health insurance in accordance with an embodiment of the present disclosure;
fig. 3 is a schematic structural diagram of an auditing apparatus for integrating medical insurance, business insurance and insurance provided in the embodiment of the present disclosure;
fig. 4 is a schematic structural diagram of another medical insurance business insurance integrated auditing device provided in the embodiment of the present disclosure;
fig. 5 is a schematic block diagram of an example electronic device 400 provided by embodiments of the present disclosure.
Detailed Description
Exemplary embodiments of the present disclosure are described below with reference to the accompanying drawings, in which various details of the embodiments of the disclosure are included to assist understanding, and which are to be considered as merely exemplary. Accordingly, those of ordinary skill in the art will recognize that various changes and modifications of the embodiments described herein can be made without departing from the scope and spirit of the present disclosure. Also, descriptions of well-known functions and constructions are omitted in the following description for clarity and conciseness.
The following describes an auditing method, an auditing device, electronic equipment and a storage medium for medical insurance business insurance integration according to an embodiment of the present disclosure with reference to the accompanying drawings.
Fig. 1 is a schematic flow chart of an auditing method for medical insurance, merchant insurance integration provided in the embodiment of the present disclosure.
As shown in fig. 1, the method comprises the following steps:
The method for identifying the user identity is not limited in the embodiment of the application. The medical insurance merchant insurance integrated control charging system can acquire user identity information and diagnosis and treatment data to be audited of a user from a user basic information base, wherein the user identity information comprises basic information such as the age, the sex and the region of the user and also comprises participation information of the user, and the diagnosis and treatment data to be audited comprise medical insurance settlement data of the user and diagnosis and treatment data such as the illness state, the medication, the treatment method and the consumable material of the user in the period of seeing a doctor.
Confirming whether the user participates in at least one of medical insurance and business health insurance, and the medical insurance reimbursement policies are different due to different participation types, so that the participation type of the user also needs to be determined, for example, after confirming that the user participates in the medical insurance, the medical insurance participated in by the user needs to be confirmed to be town medical insurance or rural cooperative medical insurance; and after confirming that the user participates in the commercial health insurance, further confirming the participation items.
It should be noted that, when the medical insurance, merchant insurance integrated audit platform does not detect any one of the medical insurance and the commercial health insurance participated in by the user, the system cannot perform the next operation, and prompts that the current user does not participate in insurance.
And 103, inputting the diagnostic data to be audited into a reimbursement audit engine corresponding to the target insurance.
After confirming that the user participates in the medical insurance/commercial health insurance, due to the fact that the types of the participating insurance are different, the auditing items are also different, therefore, the diagnostic data to be audited need to be input into the corresponding reimbursement auditing engine according to the participating condition of the user. When the user only participates in medical insurance, the auditing business is to audit whether medical insurance settlement data in the diagnostic data to be audited conform to the reimbursement policy in the planning area of the user, so that the medical insurance settlement data of the user is input into an reimbursement engine corresponding to the medical insurance for auditing.
And 104, inquiring a code library corresponding to the target insurance based on the reimbursement auditing engine, wherein the code library is a code of the name of the diagnosis and treatment data under the associated insurance participating function, and one code library is associated with the insurance participating function.
Because professional names of the same medicine, disease, treatment method and the like in platforms, systems and interiors such as his systems, different insurance companies, national medical insurance bureau and the like in a hospital are possibly different, the examination and verification are inaccurate due to the difference of the names in an examination and verification stage, and data codes designed for medical insurance supervision and verification are integrated into a medical insurance code library aiming at the condition that professional names in platforms such as his systems, national medical insurance bureau and the like in the hospital are different, wherein the data codes include but are not limited to 15 sets of data related codes of medical insurance supervision and verification, such as disease diagnosis codes, medicine codes, consumable codes and the like; the data related to the business health insurance audit is automatically coded and integrated into a business insurance code library, and the purpose of coding is to establish the relationship between different names of the same article and the treatment method, so that the same article or the treatment method can be determined even if the names are different during the audit in the follow-up process.
And 105, auditing the diagnosis and treatment data to be audited according to the query result and a preset reimbursement knowledge base.
The preset reimbursement knowledge base comprises a medical insurance policy base and a medical knowledge base, the medical insurance policy base comprises medical insurance reimbursement policies of all orchestration areas, and when auditing is performed based on the medical insurance reimbursement base, the medical insurance reimbursement policies are selected according to the orchestration areas of users for auditing; the medical knowledge base includes information on diagnosis and treatment means and medication corresponding to a disease, and disease prevention and management.
The technical scheme of the medical insurance, business and insurance integrated auditing method provided by the present disclosure includes: the method comprises the steps of obtaining diagnosis and treatment detail data to be audited, wherein the diagnosis and treatment detail data to be audited comprise user identity information and diagnosis and treatment data to be audited, determining whether to participate in target insurance or not according to the user identity information, wherein the target insurance comprises at least one of medical insurance and commercial health insurance, inputting the diagnosis and treatment data to be audited into an reimbursement auditing engine corresponding to the target insurance, inquiring a code base corresponding to the target insurance based on the reimbursement auditing engine, wherein the code base is a code of the name of the diagnosis and treatment data under the associated reimbursement insurance, one kind of the reimbursement insurance is associated with one code base, and auditing the diagnosis and treatment data to be audited according to an inquiry result and a preset reimbursement knowledge base. Compared with the prior art, the embodiment of the application finishes the examination of the medical insurance and/or the commercial health insurance of the user in the examination system integrating the medical insurance, the business insurance and the insurance after the participation type of the user is confirmed by acquiring the medical detail data to be examined of the user, does not need to rely on manpower to examine a large amount of complicated paper materials, saves labor and time cost, and greatly improves the efficiency of the examination of the commercial health insurance.
As an extension of the above application embodiment, when data encoding for medical insurance supervision and audit is performed, the following method may be adopted: and acquiring data to be coded for medical insurance supervision and audit in the overall area, coding the data to be coded, and generating the first coding library.
As an extension of the above application embodiment, when a user participates in insurance medical insurance, the medical insurance settlement data of the user is checked, and the rationality of the medical action also needs to be checked, and when the rationality of the medical action is checked, the following method can be adopted: inputting the diagnostic data to be audited into a third reimbursement audit engine; and auditing the medical diagnosis behaviors in the diagnosis and treatment data to be audited based on the third reimbursement auditing engine and the first preset reimbursement knowledge base.
An application scenario of the above application embodiment is that a user participates in only one of medical insurance and business health insurance, and the following description takes the case that the user participates in the medical insurance and the business health insurance simultaneously as an example, please refer to fig. 2, and fig. 2 is a schematic flow diagram of a method for auditing that the user participates in the medical insurance and the business health insurance simultaneously provided by the embodiment of the present disclosure, as shown in fig. 2, including:
And 203, auditing the diagnosis and treatment data to be audited according to the query result and the first preset reimbursement knowledge base.
Please refer to steps 103-105 for a process of checking medical insurance, which is not described in detail herein.
And step 204, inputting the diagnostic data to be audited into a second reimbursement audit engine corresponding to the commercial health insurance.
And after the medical insurance examination is finished, the merchant insurance health insurance examination is carried out, and the diagnostic data to be examined of the user is input into a second reimbursement examination engine corresponding to the merchant health insurance for carrying out merchant insurance rationality examination.
Since there are many commercial insurance companies and there is no uniform name for diseases, medicines and diagnosis and treatment means, the terms in the commercial insurance are coded to prevent the loss of users due to the failure of the examination and verification of the commercial health insurance caused by the different names of the same diseases, medicines and diagnosis and treatment methods.
And step 206, auditing the diagnosis and treatment data to be audited according to the query result and a second preset reimbursement knowledge base.
The second preset reimbursement knowledge base comprises commercial health insurance products and clause information corresponding to the commercial health insurance, and when the rationality analysis of the commercial insurance is carried out based on the second reimbursement auditing engine, auditing of diagnosis and treatment data to be audited is carried out by inquiring and calling clauses in the second preset reimbursement knowledge base.
As an extension of the above application embodiment, after the audit of the medical insurance settlement data based on the first reimbursement audit engine is finished, the medical insurance validity audit is executed based on the third reimbursement audit engine before the merchant insurance validity audit of the commercial health insurance is executed based on the second reimbursement audit engine.
As an extension of the above application embodiment, after the first reimbursement auditing engine executes the auditing of the medical insurance settlement data, marking the diagnosis and treatment data to be audited which do not conform to the reimbursement policy of the general area, and reminding the data to be reexamined; after auditing the rationality of the medical insurance is executed based on the third reimbursement auditing engine, marking the diagnosis and treatment data to be audited which do not accord with the rationality of the medical action, and reminding the reexamination of the diagnosis and treatment data to be audited which do not accord with the reimbursement policy of the overall planning area; after the audit of the merchant insurance settlement data is executed based on the second reimbursement audit engine, marking the to-be-audited diagnosis data which do not accord with the commercial health insurance, and suspending reimbursement of the commercial health insurance on the to-be-audited diagnosis data
As an extension to the embodiment of the above application, the method may be employed in encoding products and product terms of a commercial health insurance: and acquiring all the commercial health products in each commercial health insurance factory, analyzing to obtain reimbursement terms in all the commercial health products, and coding the reimbursement terms to generate the second coding library.
Corresponding to the medical insurance business insurance integration auditing method, the invention also provides an electric vehicle charging control device based on three-phase balance. Since the device embodiment of the present invention corresponds to the method embodiment described above, details that are not disclosed in the device embodiment may refer to the method embodiment described above, and are not described again in the present invention.
Fig. 3 is a schematic structural diagram of an auditing apparatus for integrating medical insurance, business insurance provided in an embodiment of the present disclosure, as shown in fig. 3, including:
the first obtaining unit 31 is configured to obtain medical detail data to be audited, where the medical detail data to be audited includes user identity information and medical data to be audited;
a determining unit 32, configured to determine whether to participate in target insurance according to the user identity information, where the target insurance includes at least one of medical insurance and business health insurance;
the first input unit 33 is configured to input the diagnostic data to be audited into an reimbursement audit engine corresponding to the target insurance;
the query unit 34 is configured to query, based on the reimbursement auditing engine, a code library corresponding to the target insurance, where the code library is a code of a name of the medical data under an associated insurance-participating insurance, and one insurance-participating insurance is associated with one code library;
and the first auditing unit 35 is configured to audit the diagnosis and treatment data to be audited according to the query result and a preset reimbursement knowledge base.
This public audit device of integration of guaranteeing business that provides, technical scheme includes: the method comprises the steps of obtaining diagnosis and treatment detail data to be audited, wherein the diagnosis and treatment detail data to be audited comprise user identity information and diagnosis and treatment data to be audited, determining whether to participate in target insurance or not according to the user identity information, wherein the target insurance comprises at least one of medical insurance and commercial health insurance, inputting the diagnosis and treatment data to be audited into an reimbursement auditing engine corresponding to the target insurance, inquiring a code base corresponding to the target insurance based on the reimbursement auditing engine, wherein the code base is a code of the name of the diagnosis and treatment data under the associated reimbursement insurance, one kind of the reimbursement insurance is associated with one code base, and auditing the diagnosis and treatment data to be audited according to an inquiry result and a preset reimbursement knowledge base. Compared with the prior art, the embodiment of the application finishes the examination of the medical insurance and/or the commercial health insurance of the user in the examination system integrating the medical insurance, the business insurance and the insurance after the participation type of the user is confirmed by acquiring the medical detail data to be examined of the user, does not need to rely on manpower to examine a large amount of complicated paper materials, saves labor and time cost, and greatly improves the efficiency of the examination of the commercial health insurance.
Further, in one possible implementation of this embodiment, when the target insurance is medical insurance and business health insurance;
the first input unit 33 is further configured to input the diagnostic data to be audited into a first reimbursement audit engine corresponding to the medical insurance;
the query unit 34 is further configured to query, based on the first reimbursement auditing engine, a first code library corresponding to the medical insurance;
the first auditing unit 35 is further configured to audit the medical data to be audited according to the query result and a first preset reimbursement knowledge base;
the first input unit 33 is further configured to input the diagnostic data to be audited into a second reimbursement audit engine corresponding to the commercial health insurance;
the query unit 34 is further configured to query, based on the second reimbursement and review engine, a second code library corresponding to the business health insurance;
the first review unit 35 is further configured to review the medical data to be reviewed according to the query result and a second preset reimbursement knowledge base.
Further, in a possible implementation manner of this embodiment, as shown in fig. 4, after the first auditing unit 35, the apparatus further includes:
a second input unit 36, configured to input the diagnostic data to be checked into a third reimbursement and review engine;
and a second review unit 37, configured to review the medical diagnosis behavior in the medical data to be reviewed based on the third reimbursement review engine and the first preset reimbursement knowledge base.
Further, in a possible implementation manner of this embodiment, the first auditing unit 35 is further configured to label data that does not conform to the reimbursement policy of the general planning area, and remind the reviewing of the to-be-reviewed medical data that does not conform to the reimbursement policy of the general planning area.
Further, in a possible implementation manner of this embodiment, the first auditing unit 35 is further configured to label the to-be-audited diagnostic data that does not meet the business health insurance, and suspend reimbursement of the business health insurance for the to-be-audited diagnostic data.
Further, in a possible implementation manner of this embodiment, as shown in fig. 5, the apparatus further includes:
the second obtaining unit 38 is configured to obtain data to be coded for medical insurance supervision and audit in the overall area;
a first encoding unit 39, configured to perform encoding processing on the data to be encoded, and generate the first encoding library.
Further, in a possible implementation manner of this embodiment, as shown in fig. 4, the apparatus further includes:
a third acquiring unit 310 for acquiring all the commercial health products in each commercial health insurance factory;
the analysis unit 311 is used for analyzing and obtaining reimbursement terms in all the commercial health products;
a second encoding unit 312, configured to perform encoding processing on the reimbursement clause to generate the second encoding library.
It should be noted that the foregoing explanations of the method embodiments also apply to the apparatus of this embodiment, and the principle is the same, and this embodiment is not limited.
The present disclosure also provides an electronic device, a readable storage medium, and a computer program product according to embodiments of the present disclosure.
FIG. 5 shows a schematic block diagram of an example electronic device 400 that may be used to implement embodiments of the present disclosure. Electronic devices are intended to represent various forms of digital computers, such as laptops, desktops, workstations, personal digital assistants, servers, blade servers, mainframes, and other appropriate computers. The electronic device may also represent various forms of mobile devices, such as personal digital processing, cellular phones, smart phones, wearable devices, and other similar computing devices. The components shown herein, their connections and relationships, and their functions, are meant to be examples only, and are not meant to limit implementations of the disclosure described and/or claimed herein.
As shown in fig. 5, the device 400 includes a computing unit 401 that can perform various appropriate actions and processes in accordance with a computer program stored in a ROM (Read-Only Memory) 402 or a computer program loaded from a storage unit 408 into a RAM (Random Access Memory) 403. In the RAM 403, various programs and data required for the operation of the device 400 can also be stored. The calculation unit 401, the ROM 402, and the RAM 403 are connected to each other via a bus 404. An I/O (Input/Output) interface 405 is also connected to the bus 404.
A number of components in device 400 are connected to I/O interface 405, including: an input unit 406 such as a keyboard, a mouse, or the like; an output unit 407 such as various types of displays, speakers, and the like; a storage unit 408 such as a magnetic disk, optical disk, or the like; and a communication unit 409 such as a network card, modem, wireless communication transceiver, etc. The communication unit 409 allows the device 400 to exchange information/data with other devices via a computer network, such as the internet, and/or various telecommunication networks.
Various implementations of the systems and techniques described here above may be implemented in digital electronic circuitry, Integrated circuitry, FPGAs (Field Programmable Gate arrays), ASICs (Application-Specific Integrated circuits), ASSPs (Application Specific Standard products), SOCs (System On Chip), CPLDs (Complex Programmable Logic devices), computer hardware, firmware, software, and/or combinations thereof. These various embodiments may include: implemented in one or more computer programs that are executable and/or interpretable on a programmable system including at least one programmable processor, which may be special or general purpose, receiving data and instructions from, and transmitting data and instructions to, a storage system, at least one input device, and at least one output device.
Program code for implementing the methods of the present disclosure may be written in any combination of one or more programming languages. These program codes may be provided to a processor or controller of a general purpose computer, special purpose computer, or other programmable data processing apparatus, such that the program codes, when executed by the processor or controller, cause the functions/operations specified in the flowchart and/or block diagram to be performed. The program code may execute entirely on the machine, partly on the machine, as a stand-alone software package partly on the machine and partly on a remote machine or entirely on the remote machine or server.
In the context of this disclosure, a machine-readable medium may be a tangible medium that can contain, or store a program for use by or in connection with an instruction execution system, apparatus, or device. The machine-readable medium may be a machine-readable signal medium or a machine-readable storage medium. A machine-readable medium may include, but is not limited to, an electronic, magnetic, optical, electromagnetic, infrared, or semiconductor system, apparatus, or device, or any suitable combination of the foregoing. More specific examples of a machine-readable storage medium would include an electrical connection based on one or more wires, a portable computer diskette, a hard disk, a RAM, a ROM, an EPROM (Electrically Programmable Read-Only-Memory) or flash Memory, an optical fiber, a CD-ROM (Compact Disc Read-Only-Memory), an optical storage device, a magnetic storage device, or any suitable combination of the foregoing.
To provide for interaction with a user, the systems and techniques described here can be implemented on a computer having: a Display device (e.g., a CRT (Cathode Ray Tube) or LCD (Liquid Crystal Display) monitor) for displaying information to a user; and a keyboard and a pointing device (e.g., a mouse or a trackball) by which a user can provide input to the computer. Other kinds of devices may also be used to provide for interaction with a user; for example, feedback provided to the user can be any form of sensory feedback (e.g., visual feedback, auditory feedback, or tactile feedback); and input from the user may be received in any form, including acoustic, speech, or tactile input.
The systems and techniques described here can be implemented in a computing system that includes a back-end component (e.g., as a data server), or that includes a middleware component (e.g., an application server), or that includes a front-end component (e.g., a user computer having a graphical user interface or a web browser through which a user can interact with an implementation of the systems and techniques described here), or any combination of such back-end, middleware, or front-end components. The components of the system can be interconnected by any form or medium of digital data communication (e.g., a communication network). Examples of communication networks include: LAN (Local Area Network), WAN (Wide Area Network), internet, and blockchain Network.
The computer system may include clients and servers. A client and server are generally remote from each other and typically interact through a communication network. The relationship of client and server arises by virtue of computer programs running on the respective computers and having a client-server relationship to each other. The Server can be a cloud Server, also called a cloud computing Server or a cloud host, and is a host product in a cloud computing service system, so as to solve the defects of high management difficulty and weak service expansibility in the traditional physical host and VPS service ("Virtual Private Server", or simply "VPS"). The server may also be a server of a distributed system, or a server incorporating a blockchain.
It should be noted that artificial intelligence is a subject for studying a computer to simulate some human thinking process and intelligent behaviors (such as learning, reasoning, thinking, planning, etc.), and has both hardware-level and software-level technologies. Artificial intelligence hardware technologies generally include technologies such as sensors, dedicated artificial intelligence chips, cloud computing, distributed storage, big data processing, and the like; the artificial intelligence software technology mainly comprises a computer vision technology, a voice recognition technology, a natural language processing technology, machine learning/deep learning, a big data processing technology, a knowledge map technology and the like.
It should be understood that various forms of the flows shown above may be used, with steps reordered, added, or deleted. For example, the steps described in the present disclosure may be executed in parallel, sequentially, or in different orders, as long as the desired results of the technical solutions disclosed in the present disclosure can be achieved, and the present disclosure is not limited herein.
The above detailed description should not be construed as limiting the scope of the disclosure. It should be understood by those skilled in the art that various modifications, combinations, sub-combinations and substitutions may be made in accordance with design requirements and other factors. Any modification, equivalent replacement, and improvement made within the spirit and principle of the present disclosure should be included in the protection scope of the present disclosure.
Claims (17)
1. A medical insurance, business insurance and insurance integrated auditing method is characterized by comprising the following steps:
acquiring diagnosis and treatment detail data to be checked, wherein the diagnosis and treatment detail data to be checked comprises user identity information and diagnosis and treatment data to be checked;
determining whether to participate in target insurance according to the user identity information, wherein the target insurance comprises at least one of medical insurance and business health insurance;
inputting the diagnostic data to be audited into a reimbursement audit engine corresponding to the target insurance;
inquiring a code library corresponding to the target insurance based on the reimbursement auditing engine, wherein the code library is a code of the name of the diagnosis and treatment data under the associated insurance participating insurance, and one insurance participating insurance is associated with one code library;
and auditing the diagnosis and treatment data to be audited according to the query result and a preset reimbursement knowledge base.
2. An auditing method according to claim 1 where the target insurance is medical insurance and business health insurance;
the inputting the diagnostic data to be audited into the reimbursement audit engine corresponding to the target insurance comprises:
inputting the diagnostic data to be audited into a first reimbursement audit engine corresponding to the medical insurance;
the querying, based on the reimbursement auditing engine, the code library corresponding to the target insurance comprises:
inquiring a first code library corresponding to the medical insurance based on the first reimbursement auditing engine;
the examination and verification of the diagnosis and treatment data to be examined according to the query result and a preset reimbursement knowledge base comprises the following steps:
auditing the diagnosis and treatment data to be audited according to the query result and a first preset reimbursement knowledge base;
the inputting the diagnostic data to be audited into the reimbursement audit engine corresponding to the target insurance comprises:
inputting the diagnostic data to be audited into a second reimbursement audit engine corresponding to the commercial health insurance;
the querying, based on the reimbursement auditing engine, the code library corresponding to the target insurance comprises:
querying a second code library corresponding to the business health insurance based on the second reimbursement auditing engine;
the examination of the diagnosis and treatment data to be examined according to the query result and a preset reimbursement knowledge base comprises the following steps:
and auditing the diagnosis and treatment data to be audited according to the query result and a second preset reimbursement knowledge base.
3. The review method according to claim 2, wherein after the review of the diagnosis and treatment data to be reviewed is performed according to the query result and the first preset reimbursement knowledge base, the method further comprises:
inputting the diagnostic data to be checked into a third reimbursement checking engine;
and auditing the medical diagnosis behaviors in the diagnosis and treatment data to be audited based on the third reimbursement auditing engine and the first preset reimbursement knowledge base.
4. The auditing method of claim 2, wherein the auditing the clinical data to be audited according to the query results and a first pre-established reimbursement knowledge base comprises:
marking the diagnosis and treatment data to be examined which do not accord with the reimbursement policy of the overall planning area, and reminding the reexamination of the diagnosis and treatment data to be examined which do not accord with the reimbursement policy of the overall planning area.
5. The auditing method according to claim 2, wherein auditing the clinical data to be audited according to the query results and a second preset reimbursement knowledge base includes:
and marking the to-be-audited diagnostic data which do not accord with the business health insurance, and suspending reimbursement of the business health insurance on the to-be-audited diagnostic data.
6. An auditing method according to claim 2, characterised in that the method further comprises:
acquiring data to be coded for medical insurance supervision and audit in the overall area;
and coding the data to be coded to generate the first coding library.
7. An auditing method according to claim 2, characterised in that the method further comprises:
obtaining all commercial health products in each commercial health insurance factory;
analyzing to obtain reimbursement terms in all commercial health products;
and coding the reimbursement clauses to generate the second code library.
8. The utility model provides an integrated audit device of medical insurance merchant guarantor which characterized in that includes:
the system comprises a first acquisition unit, a second acquisition unit and a processing unit, wherein the first acquisition unit is used for acquiring diagnosis and treatment detail data to be audited, and the diagnosis and treatment detail data to be audited comprises user identity information and diagnosis and treatment data to be audited;
the determining unit is used for determining whether to participate in target insurance according to the user identity information, wherein the target insurance comprises at least one of medical insurance and business health insurance;
the first input unit is used for inputting the diagnostic data to be audited into a reimbursement audit engine corresponding to the target insurance;
the query unit is used for querying a code library corresponding to the target insurance based on the reimbursement audit engine, wherein the code library is a code of the name of the diagnosis and treatment data under the associated insurance participation, and one insurance participation is associated with one code library;
and the first auditing unit is used for auditing the diagnosis and treatment data to be audited according to the query result and a preset reimbursement knowledge base.
9. The auditing device of claim 8, wherein when the target insurance is medical insurance and business health insurance;
the first input unit is further used for inputting the diagnostic data to be audited into a first reimbursement audit engine corresponding to the medical insurance;
the query unit is further configured to query a first code library corresponding to the medical insurance based on the first reimbursement auditing engine;
the first auditing unit is also used for auditing the diagnosis and treatment data to be audited according to the query result and a first preset reimbursement knowledge base;
the first input unit is further used for inputting the diagnostic data to be audited into a second reimbursement auditing engine corresponding to the commercial health insurance;
the query unit is further configured to query a second code library corresponding to the business health insurance based on the second reimbursement auditing engine;
and the first auditing unit is also used for auditing the diagnosis and treatment data to be audited according to the query result and a second preset reimbursement knowledge base.
10. An auditing apparatus according to claim 9, characterised in that after the first auditing unit, the apparatus further comprises:
the second input unit is used for inputting the diagnostic data to be audited into a third reimbursement audit engine;
and the second auditing unit is used for auditing the medical diagnosis behaviors in the diagnosis and treatment data to be audited based on the third reimbursement auditing engine and the first preset reimbursement knowledge base.
11. The review device as claimed in claim 9, wherein the first review unit is further configured to label the medical data to be reviewed that does not meet the reimbursement policy of the general area, and to remind the medical data to be reviewed that does not meet the reimbursement policy of the general area to be reviewed.
12. The auditing apparatus according to claim 9, wherein the first auditing unit is further configured to mark the to-be-audited diagnostic data that does not meet business health insurance, and suspend reimbursement of the business health insurance for the to-be-audited diagnostic data.
13. An auditing apparatus according to claim 9, characterised in that the apparatus further comprises:
the second acquisition unit is used for acquiring data to be coded for medical insurance supervision and audit in the overall area;
and the first coding unit is used for coding the data to be coded to generate the first coding library.
14. An auditing apparatus according to claim 9, characterised in that the apparatus further comprises:
a third acquiring unit for acquiring all the commercial health products in each commercial health insurance factory;
the analysis unit is used for analyzing and obtaining reimbursement terms in all the commercial health products;
and the second coding unit is used for coding the reimbursement clauses to generate the second code library.
15. An electronic device, comprising:
at least one processor; and
a memory communicatively coupled to the at least one processor; wherein the content of the first and second substances,
the memory stores instructions executable by the at least one processor to enable the at least one processor to perform the method of any one of claims 1-7.
16. A non-transitory computer readable storage medium having stored thereon computer instructions for causing the computer to perform the method of any one of claims 1-7.
17. A computer program product, characterized in that it comprises a computer program which, when being executed by a processor, carries out the method according to any one of claims 1-7.
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| CN202210636462.7A CN114723420A (en) | 2022-06-07 | 2022-06-07 | Medical insurance, business and insurance integrated auditing method and device, electronic equipment and storage medium |
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| CN202210636462.7A CN114723420A (en) | 2022-06-07 | 2022-06-07 | Medical insurance, business and insurance integrated auditing method and device, electronic equipment and storage medium |
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