JP2004288142A - System and method for paying benefit of medical insurance such as health insurance - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide a payment system of medical insurance benefit capable of easily enhancing a rate in the case of encashing a medical treatment fee credit. <P>SOLUTION: The payment system 1 is provided with a medical institute 20 which claims advance money of payment or purchase of the medical insurance benefit to an insurer 60 by indicating a specification of a claimed amount indicating the contents of a medical bill, etc. and a payment by using a computer terminal 21, etc and an advance payment institute 10 which determines an amount of advance payment or an amount of purchase of prescribed rate to the claimed amount based on information about the specification of the claimed amount, etc. and performs payment processing to the medical institute 20 at a claiming origin by using a claim information DB 11, etc. <P>COPYRIGHT: (C)2005,JPO&NCIPI

Description

[0001]
TECHNICAL FIELD OF THE INVENTION
The present invention relates to a medical insurance insurance payment system and payment method suitable for use when a medical insurance insurance payment is paid by a third-party payment institution different from the insurer.
[0002]
[Prior art]
In the conventional medical insurance system, each citizen joins medical insurance such as health insurance, mutual aid union, and national health insurance, and pays a premium every month. A certain percentage (70%, etc.) is paid from medical insurance (hereinafter, medical expenses at the rate paid from medical insurance are referred to as medical insurance insurance benefits). Each individual pays the rest of the medical expenses (30% or the like) directly (hereinafter, the medical expenses for the proportion are referred to as medical insurance self-payments).
[0003]
Medical expenses to be paid from medical insurance are calculated using the receipt (medical (dispensing) fee statement) created for each item at each medical institution such as a hospital, clinic, pharmacy, etc. , National and local governments). In practice, in many cases, the claim is once sent from each medical institution to an inspection and paying agency, which is a public institution. Then, after the contents of the receipt are examined by a staff member with specialized knowledge, each insurer is billed collectively. Payment is made by the insurer to each medical institution via an examination payment institution. In this case, the period from billing to payment is usually about two months.
[0004]
On the other hand, out-of-pocket medical expenses are usually settled for each day of medical care. After the medical treatment is completed, the insured person goes to the accounting department of the medical institution and pays the cash or the like.
[0005]
As mentioned above, payment for medical insurance benefits claimed by a claim was generally made through an appraisal and payment agency. In contrast, in recent years, IT (information technology) has been used in accordance with deregulation, so that billing / payment information can be exchanged directly between medical institutions and insurers by medical institutions and insurers without going through screening / paying institutions. Is being built. For example, there is an institution that mediates transmission and reception of a large amount of receipt information between a medical institution and an insurer, which employs a mechanism for returning a claim, for which an insurer has reserved payment, to a medical institution (for example, Patent Document 1). ). Alternatively, there is a medical institution and an insurer provided with a means for encrypting each information in order to prevent leakage of information at an intermediary institution (for example, Patent Document 2).
[0006]
In addition, there is a product that uses a business model based on factoring to shorten the period required for cashing the receivables to the examination and payment agency. One thing to keep in mind when factoring is that not all claims issued by medical institutions are assessed at their full value. In other words, if the content of the claim is inappropriate, the amount of the charge may be reduced or reserved. Therefore, in the above-mentioned products, the medical treatment claim (medical treatment claim) generated at each medical institution is not treated as a claim having 100% credit, but is treated as including a certain defect. Therefore, the claim transferee usually discounts the medical fee to about 80% and cashes it. Then, one to two months later, when the payment amount is determined by the examination and payment institution, payment for the remaining receivables is made. Therefore, the ratio of cashing at the beginning is low, for example, about 80%.
[0007]
The techniques described above are primarily for medical insurance benefits that are claimed using a claim. On the other hand, the medical insurance out-of-pocket portion is generally paid daily in cash as described above. Some medical institutions have been able to use credit cards and debit cards (for example, Patent Document 3). However, there has been no particular technical change in the system for checking claims. For example, a system that examines the contents of the copayment as in the case of the receipt examination, and reflects the ratio of the medical insurance insurance benefits to the medical insurance copayment when the request from the medical institution is reduced. There was no mechanism to make it happen.
[0008]
Insurers will also be able to conduct more detailed examinations if they are able to know the amount each medical insured has already paid as medical insurance out-of-pocket when examining the claim for medical insurance insurance benefits. At the same time, there is an idea that it is possible to monitor whether there is an error in a claim from a medical institution based on the information on the medical insurance co-payment. Therefore, there has been a request to obtain information on the medical insurance out-of-pocket portion, and a request for the discovery of a medical institution's claim error based on the information on the medical insurance out-of-pocket portion.
[0009]
[Patent Document 1]
JP 2001-344337 A (Page 3-4, FIG. 1)
[Patent Document 2]
JP-A-2002-149813 (pages 4 to 5, FIG. 1)
[Patent Document 3]
JP-A-2002-230156 (pp. 10-11, FIG. 11)
[0010]
[Problems to be solved by the invention]
The present invention has been made in view of such circumstances as described above, and in particular, a payment system and payment system for medical insurance insurance benefits that can easily improve the ratio of cashing medical fee receivables. The aim is to provide a method.
[0011]
[Means for Solving the Problems]
In order to solve the above-mentioned problem, the invention according to claim 1 is a payment method in which a reimbursement or purchase of a payment for a medical insurance insurance claim charged by a medical institution to an insurer is shown by indicating a detailed billing amount. A billing means, and for a billing amount billed by the billing means, determine a predetermined amount of a replacement payment amount or a purchase payment amount based on details of the billing amount and other information, and And a payment amount determining means for performing payment processing.
[0012]
The invention according to claim 2 further comprises a billing amount detail storing means for storing the details of the reimbursement or purchase billing amount charged by the payment claiming means, wherein the payment amount determining means includes the billing means. A predetermined percentage of the payment amount or the purchase amount is determined based on the details of the past and current billing amounts and other information stored in the billing amount accumulating means for the billed amount, and the requesting medical institution The payment processing is provided. The invention according to claim 3 is characterized in that the payment processing by the payment amount determining means is performed via a virtual branch of a financial institution.
The invention according to claim 4, further comprising: input means for inputting information on a medical insurance co-payment amount of the insured person of the insurer in the billing source medical institution; A determination unit configured to match the medical insurance co-payment amount and determine an error in the amount charged by the payment request unit;
[0013]
According to a fifth aspect of the present invention, there is provided a payment requesting step for requesting a reimbursement or a purchase of a medical insurance insurance benefit to be paid by a medical institution to an insurer, by indicating a specification of the amount of the claim, and a payment requesting step. Determines the payment amount for replacement or purchase at a predetermined rate based on the details of the billed amount and other information, and determines the payment amount to be paid to the billing medical institution And a process.
[0014]
The invention according to claim 6 is a payment requesting step for billing for the payment or purchase of the medical insurance insurance benefit to be paid by the medical institution to the insurer by indicating the details of the claim amount, and a payment requesting step. Determines the payment amount for replacement or purchase at a predetermined rate based on the details of the billed amount and other information, and determines the payment amount to be paid to the billing medical institution A program for paying for medical insurance insurance benefits, comprising a description for causing the steps to be executed by one or more computers.
[0015]
BEST MODE FOR CARRYING OUT THE INVENTION
Hereinafter, an embodiment of a medical insurance payment system to which the present invention is applied will be described with reference to the drawings. FIG. 1 is a system diagram showing one configuration example of a medical expenses payment system 1 using medical insurance. The payment system 1 of FIG. 1 includes a cashless system 100 (hereinafter referred to as a cashless system 100) relating to a co-payment of medical insurance, and a claim direct billing / settlement system 200.
[0016]
The cashless system 100 is a system that provides a function of performing a cashless settlement of a co-payment of medical insurance. The cashless system 100 is realized with a minimum configuration including the payment advance institution 10, one or more medical institutions 20, and a plurality of IC cards 31 carried by a plurality of insured persons 30. Further, both or one of the credit company 40 and the insurance company 50 can be included as a component.
[0017]
On the other hand, the claim direct billing / settlement system 200 is composed of a payment payment institution 10, one or a plurality of medical institutions 20, one or a plurality of insurers 60, and a virtual branch 70 of a financial institution. Among them, the virtual branch 70 of the financial institution can be omitted or changed to another non-virtual financial institution.
[0018]
In the payment system 1 according to the present embodiment, each medical institution 20 pays the right to pay for a medical fee (medical fee receivable) obtained by performing medical treatment for each insured person 30 and the paying institution 10 pays for it. Or buy it. However, medical reimbursement receivables paid by the medical insurance are basically paid out, and medical reimbursement receivables paid by insurance are both paid out and purchased. The payment advance organization 10 provides cash to the medical institution 20 as an advance price or a purchase price at the time of advance or purchase. On the other hand, the payment advance agency 10 requests each insured person 30 or each insured person 60 to pay cash as compensation for replacement or a request for purchase. Each insured person 30 pays the payment advance institution 10 by depositing cash into a bank account (not shown) or by providing cash through the credit company 40 or the insurance company 50. On the other hand, each insurer pays by transferring cash to a bank account (not shown) or transferring cash to a virtual branch 70 of a financial institution installed in cyber space.
[0019]
The payment transfer institution 10 is a system including a computer and its peripheral devices, and particularly includes a billing information DB (database) 11 therein. The payment advance institution 10 communicates with computers constituting the medical institution 20, the credit company 40, the insurance company 50, the insurer 60, and the virtual branch 70 via a communication line such as the Internet, a wired or wireless public network, or a dedicated line. Connected as possible.
[0020]
The billing information DB 11 includes registration information including identification information of the medical institution 20, the insured person 30, and the insurer 60 registered as using the present system 1, and transmission and reception between the medical institution 20 and the insurer 60. Electronic receipt information is recorded. The billing information DB 11 also includes billing information for a reimbursement between the reimbursement institution 10 and each medical institution 20 and information on the amount of the reimbursement, and a reimbursement between the paying institution 10 and each insured person 30. Information on the amount of money charged and information on the amount of money paid as payment for the payment are recorded. The billing information DB 11 further includes information on the amount of a claim for a direct claim between the payment institution 10 and each medical institution 20, information on the amount paid or purchased for the request, and information on the payment institution 10. Information on the amount of the claim or the amount of the claim purchased directly as a claim for replacement payment between the insurer 60 and each insurer 60, and various master data used in the claim examination are recorded.
[0021]
The medical institution 20 is a system including a computer and its peripheral devices. In this case, the medical institution 20 includes a computer terminal 21 having a display, a keyboard, a mouse, and the like, and an IC card reader / writer 22 connected to the terminal 21.
[0022]
The insured person 30 is an insured person (person or family) who has subscribed to medical insurance by the insurer 60 and carries an IC card 31 used as an insured card (insurance card) for the medical insurance. . The IC card 31 is a flat plate made of a synthetic resin on which a semiconductor device including storage means (memory) and its control device is mounted, and the storage means has an insured person certificate which is unique information for each insured person certificate. (Identification information; symbol / number of the insured person's certificate), names of one or more insured persons, insurer names, codes indicating the type of insurance, and the like.
[0023]
In the present system 1, the credit company 40 is a system including a computer and its peripheral devices. The credit company 40 charges the reimbursement agency 10 on behalf of the insured person 30 as a reimbursement. Used to pay the amount. It is assumed that each insured person 30 and the credit company 40 have signed a credit contract in advance, and that payment to the payment advance institution 10 through the credit company 40 is registered.
[0024]
In addition, the insurance company 50 is a system including a computer and its peripheral devices. In this case, the insurance company 50 has an insurance contract with the insured 30 to guarantee the co-payment of medical insurance. I do. That is, on the other hand, the insured person 30 pays a predetermined premium every month (or yearly), and the insurer 50 pays the insured person 30 when the insured person 30 needs to pay for the copayment of the medical insurance. The payment is compensated and paid on behalf of the insurer 30.
[0025]
The insurer 60 is a system including a computer and its peripheral devices, and particularly includes a qualification DB 61 inside. The qualification DB 61 is a database that records the latest qualification information on each insured person 30, 30, 30,... Of the insurer 60. In the qualification DB 61, as information indicating whether or not each insured person 30 is qualified as an insured person, an identifier of the insured person's card (identification information; a symbol / number of the insured person's card, etc.), one or more The name of the insured person, a code indicating the current type of insurance, medical treatment history information at each medical institution 20, the amount of insurance paid, and the like are recorded.
[0026]
The virtual branch 70 of a financial institution is a system composed of a computer and its peripheral devices, and is specifically one branch of a financial institution (a bank or the like) virtually existing on the Internet. The branch has a plurality of accounts, and the contractor, balance, authentication information, and the like of each account are recorded in the account DB 71, respectively. In the present system 1, the payment advance institution 10, each medical institution 20, 20, 20,... And each insurer 60, 60, 60,. are doing. .., And each insurer 60, 60, 60,..., Transfer of money to / from this one virtual branch 70 account is performed. Done by
[0027]
The configuration shown in FIG. 1 is an example of an embodiment of the present invention, and can be appropriately changed. For example, the payment advance institution 10 may be configured by distributing and distributing the plurality of payment institution 10, or may be configured integrally with the virtual branch 70 of the financial institution. In addition, the distinction between the cashless system 100 and the claim direct billing / settlement system 200 is not particularly strict, and both systems can be regarded as including respective components.
[0028]
It should be noted that the payment advancement facility 10, the medical institution 20, the credit company 40, the insurance company 50, the insurer 60, and the virtual branch 70 are composed of a computer and its peripheral devices and one or more programs executed on the computer. Be composed. The program can be distributed via a computer-readable recording medium or a communication line.
[0029]
Next, a basic operation of the cashless system 100 shown in FIG. 1 will be described with reference to FIG. 2, the same reference numerals are used for the same components as those in FIG. In the figure, the bold arrow with hatching indicates “flow of money”, and the bold white arrow indicates “flow of information”. In FIG. 2, it is assumed that the medical institution 20, the payment advance institution 10, and the insurer 60 are connected via the communication network 2. In this example, it is assumed that all the insured persons 30 of the insurer 60 have been registered as users of the cashless system by the payment advance agency 10.
[0030]
Now, it is assumed that the insured person 30 trying to receive the medical institution 20 submits the IC card 31 (insured person certificate) to the reception of the medical institution 20. It is assumed that the person in charge of the reception mounts the IC card 31 on the IC card mounting opening of the IC card reader / writer 22 and performs a predetermined operation on the computer terminal 21. Then, the computer terminal 21 reads the identification information and the like of the IC card 31 recorded on the IC card 31. Next, the computer terminal 21 requests the insurer 60 for qualification confirmation using the read identification information as key information (S10).
[0031]
The insurer 60 checks the health qualification status of the insured person 30 identified by the key information received in the qualification DB 61. If it is confirmed that the person is a valid insured person of the insurance, qualification data indicating that the insurance qualification is guaranteed (data indicating the contents of insurance and, in this case, being a user of the cashless system 100). Is returned as qualification approval information (S11). When the qualification is approved (S11), the computer terminal 21 transfers the qualification data indicating the qualification to a not-shown computer for receipt information management and accounting in the medical institution 20 (S12).
[0032]
When the insured person 30 finishes the medical treatment on that day, the insured person 30 moves to the reception of accounting. Here, it is assumed that the insured person 30 desires cashless accounting processing. The account receiver reads the IC card 31 of the insured person 30 with an IC card reader connected to an account terminal (not shown), and that the qualification has been approved at the time of reception on the screen of the terminal; Confirm that the user is a registered user of the cashless system 100. Then, the fact that the accounting process is to be performed using the cashless system 100 (ie, the cashless treatment) is recorded in the receipt information management / accounting computer in the medical institution 20 (S13). If the cashless treatment is recorded, there is no matter that the insured person 30 needs to confirm in the subsequent processing, so that the insured person 30 can leave the medical institution 20 here. However, confirmation of the intention to use the cashless system 100 may be performed at the end of the consultation.
[0033]
At the medical institution 20, after the end of the medical hours on that day, the billing amount for the medical insurance co-payment treated as a cashless system is transmitted as the daily accounting data together with the claim claim information (S14). The payment change institution 10 receives the accounting data, stores it in the billing information DB 11, and manages it (S15). The transaction data received here is managed collectively for each medical institution 20 (in this case, for each hospital) in the billing information DB 11, for example, as shown in FIG. In the example shown in FIG. 3, each insured person 30 is identified by a “name” and an “insured person symbol / number”, and further includes “medical treatment date”, “insurer name”, and “self-paid”. Information such as “ratio”, “total amount”, and “self-pay amount” is also recorded. Then, the payment amount corresponding to the invoice amount for one month on a predetermined day of each month is collectively paid out (S16).
[0034]
Next, the payment reimbursement institution 10 makes a request for reimbursement for the reimbursement for each insured person 30 on a monthly basis (S17). At the time of billing (S17), each insured person 30 confirms the contents of the payment notice / confirmation sent from the payment advance agency 10 (S18). FIG. 4 is a diagram showing an example of a payment notice / confirmation note. In each of the payment notices / confirmations shown in FIG. 4, corresponding to each insured person 30, "insured person symbol / number" as identification information, "date of consultation", "medical institution name", "billing amount" And "total out-of-pocket billing". Further, a more detailed content statement can be attached to the payment notice / confirmation statement. Then, if there is no problem in the content of the claim, each insured person 30 pays the claim amount and collects the money for the advance (S19).
[0035]
Next, the payment transfer institution 10 also provides the self-paid billing information to the insurer 60 (S20). Further, two months later, the insurer 60 receives the receipt data (data indicating the assessment result of the claim for the receipt). After confirming the examination result, the medical institution 20 returns the co-payment for the necessary assessments for changes / modifications. Actually, adjust for the following month. At the same time, additional benefits and high medical expenses are settled (S21).
[0036]
Next, another example of the processing procedure of the cashless system 100 shown in FIG. 1 will be described with reference to FIGS. As shown in FIG. 5, first, the insured person 30 performs a procedure for applying for participation in the cashless system 100 (S101). The payment institution 10 that has accepted the application for participation updates and accumulates the insured person certificate information of the insured person 30 participating in the cashless system 100 as the billing information database 11 (S102).
[0037]
On the other hand, the medical institution 20 reads the identifier of the insured person included in the IC card 31 submitted by the insured person 30 at each consultation (S103). Next, a qualification examination and a request for insured card information are transmitted to the insurer 60 using the insured person's identifier (S104).
[0038]
On the other hand, the insurer 60 updates and accumulates the identifier of the insured person, the qualification information, and the insured person identification information as the qualification database 61 (S105). Here, upon receiving the qualification examination and the request for the insured person's identification information (S104), the accumulated qualification information and the insured person's identification information are confirmed (S106). Next, the qualification examination result and the insured person identification information are transmitted to the referral source medical institution 20 (S107).
[0039]
Upon receiving the qualification examination result and the insured person identification information (S107), the medical institution 20 displays the qualification examination result and the insured person identification information on the screen (S108). Next, a request for cashless handling propriety information is transmitted to the payment reimbursement agency 10 based on the insured person's identification information (S109).
[0040]
The payment advance institution 10 checks whether the insured person 30 participates in the cashless system 100 based on the insured person's identification information of the insured person (S110). Then, the cashless system participation information is transmitted to the referral medical institution 20 (S111).
[0041]
The medical institution 20 receives the cashless system participation information (S112), and stores the identifier of the insured person, the insured person identification information, and the cashless system participation information in the terminal 21 (S113).
[0042]
Next, as shown in FIG. 6, at the end of the consultation, the medical institution 20 confirms from the insured person the intention of cashless treatment, reads the identifier of the insured person's card included in the IC card 31, and stores it in the terminal 21. The cached mark is given to the stored information, and the information is stored in the terminal 21 again (S114). After the accounting of the insured person 30, the identifier of the insured person's card included in the IC card 31 is read, the information is called up by the cashless treatment mark, and the settlement amount of the co-payment is input or transferred from the accounting system (S115). ). Next, the cashless insured person identification information, the billed amount details, and the like are transmitted to the payment reimbursement agency 10 (S116).
[0043]
The payment advance institution 10 receives and accumulates the payment request for the self-payment from the medical institution 20 (S117). Next, the processing after step S118 and the processing after step S124 are executed in parallel.
[0044]
In the processing after step S118, first, the settlement request information of the self-payment accumulated from each medical institution 20 accumulated for a certain period is totaled for each medical institution, and the advance payment amount is determined (S118). Next, a process of determining a settlement / adjustment amount is performed by sharing information with the insurer 60 (S119).
[0045]
Here, the processing content of step S119 or step S125 described later will be described with reference to FIG. In the process of determining the settlement / adjustment amount by sharing information with the insurer (S119, S125), first, as shown in FIG. The process of transmitting the supplementary benefits and the large amount of medical expenses charged to the insurer) to the insurer 60 is performed (S201). In the insurer 60, the settlement data of the co-payment for each insured person is used for examination of insurance benefits (reception examination), additional benefits, and payment of large medical expenses (S202). Next, the insurer 60 sends the medical expenses data for each insured person determined by the examination (reception examination) of the insurance benefits, the additional benefits decided by the insurer to pay, and the data of the large medical expenses to the payment institution 10. Is performed (S203). Next, the payment reimbursement institution 10 uses the medical expenses data for each insured person determined by the examination of insurance benefits (reception examination), the supplementary benefits determined by the insurer to pay, and the data of high medical expenses. Then, the settlement / adjustment amount of the copayment which has already been paid out is determined (S204).
[0046]
As described above, when the settlement / adjustment amount is determined, as shown in FIG. 7, the payment advance institution 10 determines the settlement amount to each medical institution 20 (advance payment amount−adjustment / adjustment amount). The statement is transmitted or sent (S120). Here, the medical institution 20 confirms the settlement contents (specification) from the payment advance institution 10 (S121). On the other hand, the payment transfer institution 10 performs a process of transferring the settlement amount to the account of each medical institution 20 (S122). Then, in the medical institution 20, payment is made by the payment advance institution 10 (S123).
[0047]
On the other hand, in step S124, the payment advance institution 10 sorts the settlement request information of the self-payment accumulated from each medical institution 20 accumulated for a certain period for each insured person, and considers additional benefits and high medical expenses. Then, the amount to be charged for the insured person and the insurer by advance payment is determined (S124). Next, as shown in FIG. 8, a process of determining a settlement / adjustment amount is performed by sharing information with the insurer 60 (S125).
[0048]
When the processing (S125) shown in FIG. 9 is performed as described above, the payment reimbursement institution 10 requests the insured person 30 (including the credit company 40 and the insurance company 50) and the insured person 60 to pay the amount (advance payment). ), And transmits or sends the specification (S126).
[0049]
The insured person 30 confirms the billing content (specification) from the payment advance agency 10 (S127). If there is no problem in the confirmation, the billed amount is directly deducted from the account of each insured person 30 (S128). Then, the payment processing is performed by the insured person 30 (including the credit company 40 and the insurance company 50) and the insurer 60 to the payment advance institution 10 (S129).
[0050]
On the other hand, the insurance company 50 confirms the claim content (specification) transmitted from the payment advance agency 10 (S130). The insurance company 50 transfers the amount of the claim (recovered from each individual as an insurance premium) (S131). Then, in step 129, payment processing for the payment advance agency 10 is performed.
[0051]
Further, the credit company 40 confirms the billing content (specification) transmitted from the payment advance agency 10 (S132). Then, the credit company 40 performs a process of transferring the charged amount (S133). Here, in step 129, payment processing for the payment advance institution 10 is performed. Further, the credit company 40 collects the payment from each insured person 30 after notifying each individual of the billing content (S134).
[0052]
Also, the insurer 60 checks the contents of the bill (specification) from the payment advance agency 10 (S135). If there is no problem as a result of the confirmation, the insurer 60 transfers the billed amount as it is (S136).
[0053]
Next, an example of a processing procedure of the receipt direct billing / settlement system 200 shown in FIG. 1 will be described with reference to FIG. The example shown in FIG. 10 is a case where the payment payment institution 10 purchases a claim from each medical institution 20. First, the medical institution 20 transmits to the payment advance institution 10 a request to be purchased by the payment advance institution 10 (S301). The payment recovery institution 10 compares the past several months with the previous year's month for the total number of receipts, the number of consultation days, and the number of medical treatments, and confirms that the average value is within a certain range (S302).
[0054]
Next, the payment advance institution 10 receives and obtains information on the medical insurance co-payment amount at the counter of the medical institution 20 from the outside (for example, the insurer 60), which is tabulated so as to correspond to each receipt (S303). When evaluating the contents of the billing information (recept) for the medical insurance insurance benefits to be paid by the medical institution to the insurer, the payment advance institution 10 has already paid (or paid) by the patient at the medical institution window. Should) Match with the amount information of medical insurance self-pay. Specifically, the payment transfer institution 10 checks the total billing amount converted from the total points per claim and the information of the co-payment amount, and confirms whether there is a billing error (S304).
[0055]
The amount of medical insurance benefits for one claim (created based on one patient's medical practice at the same medical institution for one patient) is converted from the total points of the relevant claim (converted at 10 yen per point) Is multiplied by the medical insurance coverage. At this time, the total billed amount should be equal to the total amount of the medical insurance insurance payment amount and the medical insurance out-of-pocket amount.
For example, use the medical insurance out-of-pocket amount obtained by summarizing the information on the medical insurance out-of-pocket amount to be paid by the patient at the medical institution window obtained through the medical insurance out-of-pocket payment advance service etc. do it,
Medical insurance insurance benefits + Medical insurance co-payments = Total billed amount
(Amount of medical insurance insurance benefits: Total billed amount x Medical insurance insurance payment ratio)
Check if the relationship is true. If this relationship is not satisfied, it is determined that the request is in error. As a result, it is possible to detect a billing error from a medical institution.
[0056]
Next, the payment clearing house 10 matches the medical treatment rule master table managed in the billing information DB 11 or the like, and evaluates the problematic receipt for an amount corresponding to a rule error or an appropriate amount of violation ( S305). Next, the assessment ratio is multiplied by a qualification error rate (probability of performing insurance medical treatment for unqualified persons) and a risk rate (predetermined safety rate) (S306). According to the above procedure, the purchase ratio is automatically calculated and the purchase price is determined (S307). Then, a process of transferring the purchase price to the medical institution 20 is performed (S308). Thus, the purchase amount is paid to the medical institution 20 from the payment advance institution 10 (S309).
[0057]
On the other hand, the payment advance agency 10 transmits a claim receipt to the insurer 60 as a portion of the payment advance agency 10 (a portion based on the purchased receivable) (S310). The insurer 60 checks the claim receipt (S311). Next, information on the payment agreement amount and a return receipt (a receipt with an incomplete description, etc.) are transmitted to the payment transfer institution 10 (S312). Here, the payment transfer institution 10 receives the information of the payment agreement amount and the return receipt from the insurer 60 (S313).
Next, the insurer 60 performs a process of transferring the agreed payment amount to the payment advance agency 10 (S314). Here, in the payment institution 10, payment is made by the insurer 60 (S315).
Next, the payment advance institution 10 makes an additional payment to the medical institution 20 according to the volume determined by the deposit amount (S316). At the medical institution 20, the payment amount paid is paid by the payment advance institution 10 (S317).
[0058]
Next, another example of the processing procedure of the receipt direct billing / settlement system 200 will be described with reference to FIG. The example shown in FIG. 11 is a case where the payment advance organization 10 advances the receipt from each medical institution 20. First, the medical institution 20 transmits a claim receipt to the insurer 60 and the payment reimbursement institution 10 (S401). The insurer 60 receives the claim receipt (S402), and examines the claim receipt (S403).
[0059]
On the other hand, the payment recovery institution 10 compares the past several months with the previous year's month with respect to the total number of receipts, the number of consultation days, and the number of medical treatments, and confirms that the average value is within a certain range (S404). .
Next, the payment advance institution 10 receives and obtains from outside (for example, the insurer 60), information on the medical insurance co-payment amount at the counter of the medical institution 20, which is tabulated so as to correspond to each receipt (S405). When evaluating the contents of the billing information (recept) for the medical insurance insurance benefits to be paid by the medical institution to the insurer, the payment advance institution 10 has already paid (or paid) by the patient at the medical institution window. Should) Match with the amount information of medical insurance self-pay. Specifically, the payment transfer institution 10 checks the total billing amount converted from the total points per claim and the information of the co-payment amount, and confirms whether there is a billing error (S406). As a result, it is possible to detect a billing error from a medical institution.
[0060]
Next, the payment transfer institution 10 matches the master table of the prescribed medical treatment rules recorded in the billing information DB 11 or the like, and evaluates the amount of the problematic receipt corresponding to a rule error or an appropriate violation. (S407). Next, a process of multiplying the assessed amount by the qualification error rate and the risk rate is performed (S408). In these processes, the ratio of the advance payment is automatically calculated, and the advance payment amount is determined (S409). The payment advance institution 10 performs a process of transferring the advance payment amount to the medical institution 20 (S410). In the medical institution 20, the payment amount is paid by the payment institution 10 (S411).
[0061]
On the other hand, the insurer 60 transmits the information of the payment agreement amount and the return receipt to the medical institution 20, and transmits the information of the payment agreement amount to the payment advance institution (S412). The medical institution 20 receives the information of the payment agreement amount and the return receipt from the insurer 60 (S413).
[0062]
On the other hand, the payment advance agency 10 receives the information of the payment agreement amount from the insurer 60 (S414). When the insurer 60 transfers the payment agreement amount to the payment reimbursement institution 10 (S415), the insurer 60 receives the payment (S416). In addition, a process of transferring the amount (remaining balance) obtained by subtracting the already paid amount from the amount received from the insurer 60 to the medical institution 20 is performed (S417). In the medical institution 20, the balance is paid by the payment advance institution 10 (S418).
).
[0063]
Next, referring to FIG. 12, an example of a claim examination by the insurer 60 (step S311 in FIG. 10 and step S403 in FIG. 11) and a method of calculating the purchase (or reimbursement) rate by the payment reimbursement organization 10 (FIG. Steps S305 to S307 and steps S407 to S409) will be described. FIG. 12 is a diagram illustrating an example of the receipt. The receipt shown in FIG. 12 has four writing defects indicated by (1) to (4).
[0064]
For example, (1) “special disease medical treatment guidance fee” has a score of 225 ((1)), and the medical fee is limited to twice a month. In addition, (2) the daily usage of “therapeutic agent for diabetes F” is “up to 0.3 mg at a time” and “up to three times a day”. It should be. In addition, in the “injury and disease name” described in (3), there is no description of an appropriate purpose of use of the “oral agent (mouthwash) G”. Essentially unnecessary drugs are prescribed. {Circle around (4)} The "claim point" should be "2896". That is, the total of “948 points” for (1) (225 points), (2) (700 points), and (3) (23 points) is considered to be surplus claims.
[0065]
Although the above determination is a detailed determination, the determination of the purchase (replacement) ratio in the payment replacement agency 10 of the present embodiment is determined by setting an original “evaluation level”. For example, level A ... Not recognized. Level AB: May be recognized for a reason. Level B: There is a high possibility of being recognized. Level C: The evaluation is performed in four steps, such as generally recognized, and the ratio is determined.
[0066]
In this case, in the above example, evaluations of (1) = A, (2) == AB, and (3) = B are made. Therefore, (1) is a "item for which payment is not made", (2) is "possible to be paid in some cases", and (3) is if an indication is given (or the amount as it is). Will be "paid" because it is likely to be accepted because it is small. Therefore, it is considered that “approximately 3619 to 3000 points” is possible as the evaluation of this claim, and this possibility becomes “evaluation rate (90% or the like)”, and the final evaluation of the receipt is performed. These evaluations are further calculated and corrected based on original evaluation criteria determined by analysis of experience values and past data.
[0067]
The main functions in the embodiment shown in FIG. 1 are summarized in FIG. That is, the functions realized by the computer terminal 21 or the like of the medical institution 20 include the identification information reading function F21 of the IC card 31 and the guarantee status checking function (first checking means) F22 for checking the qualification of the insured person 30. A registered insured person confirmation function (second confirmation means) F23 for confirming the insured person 30's cashless system use registration, a reimbursement payment request function F24 for requesting a medical insurance co-payment, and medical insurance There is a payment request function F25 for requesting insurance payment. The functions realized by the computer of the payment advance institution 10 include a target insured person registration function F11 for registering the use of the insured person 30 in the cashless system, and a function for storing and managing billing information from the medical institution 20. Function F12 for determining the amount to be charged to the insured 30; function F13 for determining the amount to be insured for the insured 30; Advance payment amount determining function F14, a predetermined percentage advance payment amount or purchase payment amount is determined based on the details of the billing amount and other information, and a payment amount determining function F15 for processing payment to the billing medical institution. Payment adjustment function F16 for adjusting the payment amount to the medical institution 20 according to the claim assessment of the insurance payment, etc. There is a claim error determination function F17 for inputting information on the medical insurance out-of-pocket amount of the insured person of each insurer in the medical institution, reconciling the billed amount with the medical insurance out-of-pocket amount, and determining an error in the billed amount. . In FIG. 13, functions forming a pair with respect to the self-paid portion and the insurance payment portion are shown by chain lines.
[0068]
【The invention's effect】
According to the present invention, there is provided a billing means for billing for the payment or purchase of a medical insurance insurance benefit to be paid by a medical institution to an insurer by indicating a billing amount, and a billing means for billing. Payment amount determining means for determining a predetermined percentage of a payment amount or a purchase payment amount based on the details of the charged amount and other information with respect to the charged amount, and performing payment processing to the requesting medical institution. With this arrangement, it is possible to more accurately predict the assessed amount of the medical treatment fee by the insurer, so that it is possible to easily improve the ratio of cashing the medical fee receivable.
[0069]
In addition, there is provided a billing detail storage means for storing the details of the reimbursement or purchase demand billed by the payment demanding means, and the payment amount deciding means is adapted to pay the billing amount by the payment demanding means. Since a predetermined percentage of the replacement payment amount or the purchase amount is determined based on the details of the past and current billing amounts and other information stored in the storage means, and the payment is made to the billing medical institution. In the process of determining the ratio, for example, a simple estimation of the assessment ratio is made by comparing the details of the past and present invoiced amounts, and the details of the invoiced amounts are examined based on the prediction result. Processing can be appropriately selected and performed, and more efficient processing can be expected.
[0070]
In addition, by performing the payment processing by the payment amount determining means through the virtual branch of the financial institution, the transfer processing can be completed within the same branch, which is advantageous in terms of fees and time.
[0071]
An input unit for inputting information on a medical insurance co-payment amount of the insured person of the insured person at the billing source medical institution; a billing amount charged by the payment requesting unit; Since there is provided a determination unit that matches the amount of money and determines an error in the amount charged by the payment request unit, it is possible to detect an error in a charge from a medical institution.
[Brief description of the drawings]
FIG. 1 is a system diagram showing a configuration example of a payment system 1 (a cashless system 100 and a claim direct settlement / payment system 200 relating to a co-payment of medical insurance) as an embodiment of the present invention.
FIG. 2 is a conceptual diagram showing a basic processing flow by the cashless system 100 of FIG. 1;
FIG. 3 is a diagram showing an example of accumulation of accounting data in FIG. 2;
FIG. 4 is a diagram showing an example of billing information for an insured person 30 in FIG. 2;
FIG. 5 is a flowchart showing a processing flow in the cashless system 100 of FIG. 1 (continued to FIG. 6);
6 is a flowchart showing a flow of processing in the cashless system 100 of FIG. 1 (continuation of FIG. 5 and continuation of FIG. 7);
7 is a flowchart showing a flow of processing in the cashless system 100 of FIG. 1 (continuation of FIG. 6 and continuation of FIG. 8);
8 is a flowchart showing the flow of processing in the cashless system 100 of FIG. 1 (continuation of FIG. 7);
9 is a flowchart showing the processing contents of step S119 in FIG. 7 and step S125 in FIG.
10 is a flowchart showing an example of processing by the receipt direct billing / settlement system 200 of FIG. 1 (for purchase)
FIG. 11 is a flowchart showing an example of processing by the claim direct billing / settlement system 200 of FIG. 1 (in the case of advance payment).
FIG. 12 is a diagram showing an example of a claim for explaining a claim examination example and a purchase (replacement payment) ratio evaluation example;
FIG. 13 is a block diagram showing an outline of main functions of the embodiment of the present invention shown in FIG. 1;
[Explanation of symbols]
1 Payment system
10 Payment organization
11 Billing information DB (database)
21 Computer terminal
22 IC card reader / writer
31 IC card
61 Qualification DB (Database)
100 Cashless system for copayments (cashless system)
200 Receipt direct billing and settlement system

Claims (6)

Payment requesting means for requesting a reimbursement or purchase of a payment for medical insurance insurance benefits to be paid by a medical institution to an insurer, showing the details of the claim amount,
Payment to determine the payment amount or purchase payment amount at a predetermined ratio based on the details of the charged amount and other information with respect to the amount charged by the payment request means, and to pay the billing medical institution A payment system for medical insurance insurance benefits, comprising: an amount determining means. Further, a billing amount accumulating means for accumulating the details of the reimbursement or purchase billing amount charged by the billing means,
The payment amount determining means substitutes a predetermined ratio of the amount charged by the payment requesting means based on the details of the past and current charges stored in the charged amount details storing means and other information. 2. The payment system for medical insurance insurance benefits according to claim 1, wherein a payment amount or a purchase amount is determined and payment processing is performed to a requesting medical institution. The payment system for medical insurance insurance benefits according to claim 1, wherein the payment processing by the payment amount determination unit is performed through a virtual branch of a financial institution. Further, input means for inputting information on the medical insurance co-payment amount of the insured person of the insurer in the claim source medical institution,
The method according to claim 1, further comprising a determination unit configured to match the amount claimed by the payment unit with the amount paid by the medical insurance co-payment and determine whether the amount claimed by the payment unit is incorrect. The payment system for medical insurance insurance benefits according to claim 3. A billing process for billing the reimbursement or purchase of the medical insurance insurance benefits to be paid by the medical institution to the insurer, showing the details of the claim amount;
With respect to the amount charged in the payment request process, a predetermined percentage of the payment amount for replacement or the purchase payment amount is determined based on the details of the charged amount and other information, and the payment is made to the billing medical institution. A method of paying medical insurance insurance benefits, comprising a step of determining a payment amount. A billing process for billing the reimbursement or purchase of the medical insurance insurance benefits to be paid by the medical institution to the insurer, showing the details of the claim amount;
With respect to the amount charged in the payment request process, a predetermined percentage of the payment amount for replacement or the purchase payment amount is determined based on the details of the charged amount and other information, and the payment is made to the billing medical institution. A payment program for medical insurance insurance benefits, including a description for causing the payment amount determining process to be executed by one or more computers.

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