CN115049512A - Intelligent claim settlement accounting system - Google Patents
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Abstract
The invention relates to the technical field of insurance claim settlement, and discloses an intelligent claim settlement accounting system, which comprises: the system comprises an entry module, a rule configuration module, an audit module and an settlement module, wherein the entry module is used for collecting and entering case information, the rule configuration module is used for configuring settlement rules according to the case information, the audit module is used for auditing the case information and the settlement rules, and the settlement module is used for calculating a settlement result according to the case information and the settlement rules. According to the invention, through the full-flow information input, configuration, audit and claim settlement programs, the claim settlement efficiency and the fee control wind control capability can be improved, and the customer claim settlement experience and satisfaction are improved.
Description
Technical Field
The invention relates to the technical field of insurance claim settlement, in particular to an intelligent claim settlement accounting system.
Background
The development of emerging technologies such as cloud computing, big data, artificial intelligence and block chains brings opportunities for remodeling and reconstruction of value chains of various links in the insurance industry. From the actual landing situation, the application degree of the insurance technology in the product research and development link is relatively shallow, and the method is mainly used for assisting a actuarian to carry out risk pricing and customized product development on the basis of big data analysis; secondly, in the insurance marketing link, as the pain points are more and the business scene is more beneficial to the falling of technologies such as AI big data and the like, the link becomes the most falling link of the current insurance technology; in the links of underwriting and claim settlement, the value of insurance technology lies in helping enterprises to improve wind control capability and efficiency and improve user experience, and the method is the future core competitiveness of insurance enterprises.
At present, in the four core links (product design, marketing and sales, underwriting and insurance acceptance, claim settlement and service) of the value chain of the insurance industry, each existing flow has almost the space and case for changing the new technology. In the product design link, the establishment of a customer database and the addition of external data enable product optimization based on specific population to be possible, for example, various customized insurance products based on scenes appear; in the marketing and distribution link, accurate marketing decision can be made based on the user image, potential customers can be predicted, the customer loss can be prevented, and the management capability of a plurality of reach channels is greatly enhanced; in the link of underwriting and underwriting, the short-term change mainly lies in the automation of the process, for example, the life insurance underwriting rule is online, and the automatic underwriting can be completed only by acquiring the authorization data of the user; in the claim settlement and service link, anti-fraud, robot customer service and the like based on big data are put into use firstly, and next, each side ecology is linked, and automatic claim settlement service decision is carried out based on a data model.
The social contact, consumption and other behaviors of the domestic C-end user are prior to the internal operation management of the insurance industry to enter a digitization stage, and the interaction channel directly facing the terminal client is changed firstly; and then, the insurance product can be reversely customized according to the user preference through data such as user figures accumulated by a digital channel. Claim settlement and service are the next link to be promoted, and the driving force comes from two aspects: firstly, user experience is improved; second, insurance companies have fee control requirements for incrementally slowed market segments, such as car insurance. At present, the capacity of links such as rate determination, insurance pricing and the like in the insurance industry is poor, namely, an insurance company and the like lack effective data and analysis capacity, and are difficult to accurately predict pure risk loss and formulate channel cost and the like, so that part of dangerous seed loss generally exists. For example, the health risks of the insurance policy, such as severe risk, are not accurate due to lack of relevant medical data, such as treatment cost data and recurrence data of thyroid cancer, and the incidence of the serious risk insurance policy is higher than the overall incidence of the disease because the health condition data of the insurance applicant cannot be comprehensively mastered. Therefore, how to improve the claim settlement efficiency and the cost control wind control capability in the claims and services becomes a problem to be solved urgently in the insurance technology at present.
Disclosure of Invention
The invention aims to provide an intelligent claim settlement accounting system which can improve the claim settlement efficiency and the fee control and wind control capability and improve the claim settlement experience and satisfaction of customers through the full-flow information input, configuration, audit and claim settlement programs.
The technical scheme provided by the invention is as follows: an intelligent claims settlement accounting system, comprising: the system comprises an entry module, a rule configuration module, an audit module and an settlement module, wherein the entry module is used for collecting and entering case information, the rule configuration module is used for configuring settlement rules according to the case information, the audit module is used for auditing the case information and the settlement rules, and the settlement module is used for calculating a settlement result according to the case information and the settlement rules.
The working principle and the advantages of the invention are as follows: the invention collects and inputs case information of a user through the input module, the rule configuration module configures claim settlement rules according to the case information, the auditing module audits the case information and the claim settlement rules, and the claim settlement module calculates the claim settlement results according to the case information and the claim settlement rules. Through the information input, configuration, audit and claim settlement procedures of the whole process, the completeness of case information, the reasonability of claim settlement rules and the time limitation of the settlement process can be ensured, compared with the traditional claim settlement mode, the case claim settlement efficiency is improved, the cost control and wind control capability of claim settlement is improved, and therefore the customer claim settlement experience and satisfaction are improved.
Further, the logging module comprises an online logging unit and an offline logging unit, the online logging unit is used for logging electronic data of case information, and the offline logging unit is used for logging entity materials of the case information.
And non-entity case information such as certificate numbers, personnel information and the like is directly recorded on line, so that the method is simple and rapid. And for the entity materials of case information, such as paper materials and the like, the information is recorded into the system in a way of downloading and uploading through a line so as to ensure the maximum integrity of the case information.
Further, the offline entry unit comprises an image processing unit, an OCR recognition unit and a keyword extraction unit, the image processing unit is used for carrying out sharpening processing and classification on the solid material image, the OCR recognition unit is used for carrying out OCR recognition on the solid material image and extracting a text, and the keyword extraction unit is used for extracting keywords in the text.
The entity material is uploaded to the system in an image mode, and then the system carries out the steps of sharpening processing, OCR recognition and keyword extraction on the image so as to automatically recognize key information in the image, avoid the step of manually inputting related information, and save time and labor.
Furthermore, the input module further comprises a structured arrangement unit, and the structured arrangement unit is used for carrying out structured processing and classified arrangement on the input case information.
And carrying out structured processing on the collected case information to accord with the format of the background database, sorting the case information according to the classification, and storing the case information into the background database to provide data support for subsequent links of settlement and claim settlement.
Further, the rule configuration module comprises an insurance policy number configuration unit, a hierarchy parameter configuration unit and a claim settlement rule generation unit, the insurance policy tree configuration unit is used for performing tree logic disassembly on case information, the hierarchy parameter configuration unit is used for configuring corresponding parameter rules for each hierarchy according to the tree logic, and the claim settlement rule generation unit is used for generating comprehensive claim settlement rules according to the parameter rules of each hierarchy.
And carrying out preliminary logic disassembly on case information through the tree logic relationship, configuring corresponding parameter rules for each hierarchy, and generating comprehensive claim settlement rules according to the parameter rules of each hierarchy. Through the method, the fine claim settlement rule configuration can be performed on the case, the accuracy of the claim settlement rule is guaranteed, and the subsequent calculation claim checking efficiency and the cost control wind control capacity are improved.
Further, the policy tree configuration unit performs tree logic disassembly on the case information according to the policy-grade-product-risk species-responsibility tree logic.
Through the policy-grade-product-risk species-responsibility tree logic, the logic and the regularity of the claim settlement rule configuration process can be effectively ensured, and the wind control capability is ensured.
Further, the hierarchical parameter configuration unit includes a basic parameter configuration unit and a general parameter configuration unit, the basic parameter configuration unit is configured to configure corresponding basic parameter rules for each hierarchy according to tree logic, and the general parameter configuration unit is configured to configure corresponding general parameter rules for each hierarchy according to tree logic; the basic parameters comprise one or more of limit, responsibility range, exempt sequence, exempt amount, total exempt amount, claim proportion, entity limit, total limit and basic settlement, and the general parameters comprise one or more of settlement audit rule matching, past medical history code, clinic special disease, doctor definition, third party deduction, medical insurance card use rule, hospital code, settlement sequence, waiting period, fund sequence, except responsibility, type of responsibility service, accident diagnosis and diagnosis conversion.
Basic parameters refer to calculation related parameters, general parameters refer to case audit related parameters, and the calculation and audit are respectively refined and configured one by one, so that the fee control and wind control capability of rule configuration is guaranteed to the maximum extent.
Furthermore, the auditing module comprises a primary auditing unit and a secondary auditing unit, wherein the primary auditing unit is used for manually configuring the unsuccessfully configured case information, and the secondary auditing unit is used for identifying the risk case information and noting the risk prompt.
And the accuracy and the wind control capability of the rule configuration process are guaranteed through the secondary audit of the primary audit and the secondary audit of the secondary audit.
Further, the settlement module comprises a claim detail collection unit, a liability determination unit and a case settlement unit, wherein the claim detail collection unit is used for collecting and storing claim detail information in case information, the liability determination unit is used for determining liability of cases, and the case settlement unit is used for calculating a claim settlement result according to the claim detail information and a claim settlement rule.
And acquiring claim detail information in the case information for subsequent settlement and query, and finally calculating a claim settlement result according to the claim detail information and the claim settlement rules on the premise that the settlement takes the responsibility problem of determining the case, wherein the whole process is standard and reasonable, and the result can be recycled.
Furthermore, the calculation module also comprises a case finalizing unit, and the case finalizing unit is used for finalizing the case and preventing the case from being tampered.
And carrying out case finalization anti-tampering treatment on cases to prevent other personnel from carrying out related operations on the cases finalized.
Drawings
Fig. 1 is a block diagram of an intelligent claim settlement accounting system according to an embodiment of the present invention.
Detailed Description
Embodiments of the present invention will be described in detail below with reference to the accompanying drawings. The following examples are only for illustrating the technical solutions of the present invention more clearly, and therefore are only examples, and the protection scope of the present invention is not limited thereby.
It is to be noted that, unless otherwise specified, technical or scientific terms used herein shall have the ordinary meaning as understood by those skilled in the art to which the invention pertains.
Example (b):
as shown in fig. 1, the present embodiment discloses an intelligent claim settlement accounting system, which includes an entry module, a rule configuration module, an audit module, and a settlement module.
The input module is used for collecting and inputting case information, a user can put forward an application for claim settlement on line through the input module, sequentially fills in the application information and the information of the payee, and uploads the claim settlement materials. The entry module comprises an online entry unit and an offline entry unit, the online entry unit is used for entering electronic data of case information, and a user enters certificate numbers, mobile phone numbers, verification codes, information such as claim types, treatment dates, treatment places, accident reasons and the like on the online entry unit; inputting the name of the payee, the relationship with the insured, the bank card number, the bank of the account and other information; the uploaded claim settlement materials comprise five types of information including the certificate information of the insured, the certificate information of the payee, the bank account data, the invoice expense receipt, the medical history materials (diagnosis information, medicine prescription information and the like) and other data.
The offline entry unit is used for entering entity materials of case information and comprises an image processing unit, an OCR recognition unit and a keyword extraction unit, the image processing unit is used for carrying out sharpening processing on the entity material images, the OCR recognition unit is used for carrying out OCR recognition on the entity material images and extracting texts, and the keyword extraction unit is used for extracting keywords in the texts. For paper claim settlement materials submitted offline, a system carries out sharpening processing on uploaded image data, for example, aiming at the problem that collected images are not sharp due to the field environment, the images are analyzed frame by frame, a plurality of images with the minimum chromatic aberration are selected, an image with stable ambient light is generated through an image multi-frame fusion algorithm, and then the image contrast is enhanced, and the color is enhanced. The processed images can realize the classification of claim settlement basic images (bank cards, identity cards and the like) and claim settlement medical images (medical records, expense lists, laboratory test reports and the like). And then performing OCR recognition on the processed image, and extracting text information in the image through an entity extraction algorithm based on a knowledge graph. The keywords in the text information are extracted, and the images can be further classified according to the keywords in the embodiment. Aiming at the expense bill, after the system is identified by an OCR technology, the system carries out identification and splitting on the expenses of outpatient service, hospitalization and the like item by item, and the expenses are sorted in a structured data form and then stored in a background database. The image information such as the insured certificate information, the payee certificate information, the bank account data, the invoice expense receipt, the medical history material (diagnosis information, medicine prescription information and the like), other data and the like is structured and then stored in a background database, so that data support is provided for the subsequent links of settlement and claim check.
Through the input module, the user completes the filing of the application information, the filling of the information of the payee and the uploading of the claim settlement data in sequence on the terminal equipment according to the flow guidance. After the claim settlement application is successfully submitted, the claim settlement progress and the claim settlement result can be checked at any time. The method changes the complex and complicated case-reporting flow of the traditional insurance claim settlement, improves the claim settlement efficiency, saves the labor cost, and realizes the digitization and the intellectualization of the claim settlement.
The rule configuration module is used for configuring the claim settlement rules according to the case information. The rule configuration module comprises a policy number configuration unit, a hierarchy parameter configuration unit and a claim settlement rule generation unit. And the policy tree configuration unit performs preliminary tree logic disassembly on case information according to policy-grade-product-dangerous species-responsibility tree logic.
The hierarchical parameter configuration unit is used for configuring corresponding parameter rules for each hierarchy according to the tree logic. The hierarchical parameter configuration unit comprises a basic parameter configuration unit and a general parameter configuration unit, the basic parameter configuration unit is used for configuring corresponding basic parameter rules for each hierarchy according to the tree logic, and the general parameter configuration unit is used for configuring corresponding general parameter rules for each hierarchy according to the tree logic
In this embodiment, the basic parameters refer to parameters related to case settlement, including quota, responsibility range, claim-free sequence, claim-free amount, total claim-free amount, claim payment ratio, entity quota, total quota, and basic settlement. The general parameters refer to case auditing related parameters, and comprise claim auditing rule matching, past medical history codes, out-patient special diseases, treatment definition, third party deduction, medical insurance card use rules, hospital codes, accounting sequence, waiting period, fund sequence, excluded responsibility, responsibility service type, accidental diagnosis, diagnosis conversion and the like.
And the basic parameter configuration unit further performs detailed configuration according to the tree logic for each parameter in the basic parameters. For example, for the quota parameter, the system supports configuration of corresponding quota information at a product, risk and responsibility level mainly according to quota information related to service configuration. The quota parameter comprises information such as parameter codes, parameter types, parameter description, detailed contents and the like. If the quota is limited by special diagnosis and treatment details, the quota can be configured to only act on the diagnosis and treatment (medicines, consumables and medical services) data, and the quota detail with special requirements is subjected to quota code type detail setting, wherein the quota code type setting comprises code type, quota description, start code, end code and quota code information. If the quota has special diagnosis limitation, the detail information of the quota with special requirements can be configured for the disease range, and the quota is configured to only be effective for which diagnoses. The disease scope detail information configuration comprises parameter codes, parameter types, start codes and end code information. Other parameters in the basic parameters are configured in a detailed mode, and the parameters can be configured one by one according to the configuration mode of the quota parameters.
And the general parameter configuration unit further performs detailed configuration according to the tree logic for each parameter in the general parameters. For example, the past medical history code parameter configuration is mainly to configure the past medical history category according to the service, so that the configured past diseases are intercepted and prompted in the claims link. The system supports configuration of corresponding prior medical history code information (prior medical history code parameters are generally directly configured in a security layer) at a policy, risk category and responsibility level, and the prior medical history code parameters comprise parameter codes, parameter types, parameter descriptions, detailed contents and other information. The function is mainly to set detailed content information of the past medical history code parameters according to business requirements, wherein the detailed content information comprises the past medical history code, the code type, the start code, the start and stop code description, the stop code description and the past medical history description information. Other parameters in the general parameters are configured in a detailed mode, and can be configured one by one according to the configuration mode of the past medical history code parameters.
And the claim settlement rule generating unit generates a comprehensive claim settlement rule according to the configured parameter rules of all levels. Through comprehensive claim settlement rules, products, dangerous seeds and responsibilities are uniformly mapped, and a good foundation is laid for subsequent policy configuration, case automatic liability assignment and settlement.
The auditing module is used for auditing case information and claim settlement rules. The auditing module comprises a primary auditing unit and a secondary auditing unit, wherein the primary auditing unit is used for manually configuring the unsuccessfully configured case information. In the process of case information configuration claim rules, the unsuccessfully configured case information, namely the case information with low matching degree, is converted into manual configuration operation, aiming at mapping the expense detail recorded in the claim case information to standard diagnosis and treatment data in the system and laying a foundation for subsequent policy configuration and case automatic liability determination and calculation.
And the review unit is used for identifying the risk case information and commenting the risk prompt. The system sets diagnosis and recheck recognition rules, carries out risk remark prompting operation on intercepted cases/bills, aims to carry out recognition remark on claims cases possibly with high risk, provides corresponding risk prompting information for subsequent operating personnel when examining the claims cases, and ensures that the claim results of the claims cases are correct.
The settlement module is used for calculating a settlement result according to the case information and the settlement rule. The settlement module comprises a claim detail unit, a responsibility determination unit, a case settlement unit and a case settlement unit, wherein the claim detail unit is used for collecting and storing claim detail information in case information, the responsibility determination unit is used for determining responsibility for a case, the case settlement unit is used for calculating a claim result according to the claim detail information and a claim rule, and the case settlement unit is used for performing case settlement anti-tampering processing on the case.
The claim settlement detail information comprises detail information of a case layer, a diagnosis layer, an invoice layer, a detail layer and a fee deduction information layer. In the case layer, when the case initially comes in, the case accountability unit can automatically perform accountability on the case. After determining the responsibility, the case settlement unit automatically settles the cases according to the settlement detail information and the settlement rules, and the settlement result comprises information such as applicant name, insured person ID, applicant certificate number, client application number, order number, account name, total amount, deduction amount, particle calculation amount, settlement amount, final settlement amount, settlement conclusion, conclusion description, case state and the like.
After the case is managed and calculated, the case settlement unit carries out case settlement anti-tampering processing on the case, and related operations cannot be carried out on the case after the case settlement.
The system in the embodiment also comprises a comprehensive query module which is used for querying case claim settlement information. The comprehensive query module can query circulation flows of all batches in the settlement and calculation claims and the input information of cases under the batches, and aims to monitor the flows of the batches. The detailed information includes application number, case number, online/offline, case source, insurance policy number, insurance unit, case status, case detailed information, application detailed information, and the like. The case detailed information includes an application number, a case number, an operator, operation time, and an operation state (a text matching task to be generated, text matching to be performed automatically, a text matching task to be generated successfully, a self-photographing matching failure to enter manual matching, and the like). The application detail information comprises three layers of case, bill and expense details. The detailed bill information includes information such as the date of visit, date of admission, date of discharge, hospital name, hospital code of visit, department code, diagnosis description, disease code, bill type, bill number, invoice amount, social security payment amount, classified self-payment amount, self-fee amount, other party payment, image serial number, invoice name, medical insurance place, diagnosis times and the like.
The foregoing are merely exemplary embodiments of the present invention, and no attempt is made to show structural details of the invention in more detail than is necessary for the fundamental understanding of the art, the description taken with the drawings making apparent to those skilled in the art how the several forms of the invention may be embodied in practice with the teachings of the invention. It should be noted that, for those skilled in the art, without departing from the structure of the present invention, several changes and modifications can be made, which should also be regarded as the protection scope of the present invention, and these will not affect the effect of the implementation of the present invention and the practicability of the patent. The scope of the claims of the present application shall be determined by the contents of the claims, and the description of the embodiments and the like in the specification shall be used to explain the contents of the claims.
Claims (10)
1. An intelligent claim settlement accounting system, comprising: the system comprises an entry module, a rule configuration module, an audit module and an settlement module, wherein the entry module is used for collecting and entering case information, the rule configuration module is used for configuring settlement rules according to the case information, the audit module is used for auditing the case information and the settlement rules, and the settlement module is used for calculating a settlement result according to the case information and the settlement rules.
2. The intelligent claim settlement accounting system of claim 1, wherein: the logging module comprises an online logging unit and an offline logging unit, the online logging unit is used for logging electronic data of case information, and the offline logging unit is used for logging entity materials of the case information.
3. The intelligent claim settlement accounting system of claim 2, wherein: the offline entry unit comprises an image processing unit, an OCR recognition unit and a keyword extraction unit, the image processing unit is used for carrying out sharpening processing and classification on the solid material image, the OCR recognition unit is used for carrying out OCR recognition on the solid material image and extracting a text, and the keyword extraction unit is used for extracting keywords in the text.
4. The intelligent claim settlement accounting system of claim 2, wherein: the input module further comprises a structured arrangement unit, and the structured arrangement unit is used for carrying out structured processing and classified arrangement on the input case information.
5. The intelligent claim settlement accounting system of claim 1, wherein: the rule configuration module comprises an insurance policy number configuration unit, a hierarchy parameter configuration unit and a claim settlement rule generation unit, wherein the insurance policy tree configuration unit is used for performing tree logic disassembly on case information, the hierarchy parameter configuration unit is used for configuring corresponding parameter rules for each hierarchy according to the tree logic, and the claim settlement rule generation unit is used for generating comprehensive claim settlement rules according to the parameter rules of each hierarchy.
6. The intelligent claim settlement accounting system of claim 5, wherein: and the policy tree configuration unit performs tree logic disassembly on case information according to policy-grade-product-dangerous species-responsibility tree logic.
7. The intelligent claim settlement accounting system of claim 5, wherein: the hierarchical parameter configuration unit comprises a basic parameter configuration unit and a general parameter configuration unit, the basic parameter configuration unit is used for configuring corresponding basic parameter rules for each hierarchy according to tree logic, and the general parameter configuration unit is used for configuring corresponding general parameter rules for each hierarchy according to the tree logic; the basic parameters comprise one or more of limit, responsibility range, exempt sequence, exempt amount, total exempt amount, claim proportion, entity limit, total limit and basic settlement, and the general parameters comprise one or more of settlement audit rule matching, past medical history code, clinic special disease, doctor definition, third party deduction, medical insurance card use rule, hospital code, settlement sequence, waiting period, fund sequence, except responsibility, type of responsibility service, accident diagnosis and diagnosis conversion.
8. The intelligent claim settlement accounting system of claim 1, wherein: the auditing module comprises a primary auditing unit and a secondary auditing unit, wherein the primary auditing unit is used for manually configuring the unsuccessfully configured case information, and the secondary auditing unit is used for identifying the risk case information and commenting the risk prompt.
9. The intelligent claim settlement accounting system of claim 1, wherein: the settlement module comprises a settlement detail unit, a liability assignment unit and a case settlement unit, wherein the settlement detail unit is used for collecting and storing settlement detail information in case information, the liability assignment unit is used for assigning liability to cases, and the case settlement unit is used for calculating a settlement result according to the settlement detail information and settlement rules.
10. The intelligent claim settlement accounting system of claim 9, wherein: the calculation module also comprises a case finalizing unit, and the case finalizing unit is used for finalizing the case and preventing the case from being tampered.
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN116342298A (en) * | 2023-03-07 | 2023-06-27 | 国任财产保险股份有限公司 | Claim settlement system for non-vehicle insurance |
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| Publication number | Priority date | Publication date | Assignee | Title |
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| CN116342298A (en) * | 2023-03-07 | 2023-06-27 | 国任财产保险股份有限公司 | Claim settlement system for non-vehicle insurance |
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