JP2006323520A - Method, program and device for checking nursing service appropriateness and recording medium - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To efficiently check whether an inappropriate nursing service is given to the insured. <P>SOLUTION: This is a nursing service appropriateness checking method in a nursing service appropriateness checking device which checks the appropriateness of a nursing service. In addition, the nursing service appropriateness checking device includes a nursing service appropriateness checking step which checks the appropriateness of a nursing service by using approval data on the mind and body state of the insured of the nursing-care insurance, and stored in the approval data storage means of the nursing service appropriateness checking device, and coverage data relating to the charge of a nursing service given to the insured of the nursing-care insurance, the coverage data being stored in the coverage data storage means of the nursing service appropriateness checking device; and a check-result displaying step which displays the result of the checking executed in the nursing service appropriateness checking step. <P>COPYRIGHT: (C)2007,JPO&INPIT

Description

  The present invention relates to a care service suitability check method, a care service suitability check program, a recording medium, and a care service suitability check device.

  With the aging of society, the kitchen situation of the nursing insurance finance of the local government (or nursing care insurer) is getting harder.

JP-A-11-175615

  Under such circumstances, conventionally, there has been no technology for checking the provision of inappropriate care services (for example, care services unnecessary for the insured person or excessive care services). Therefore, for example, even if an inappropriate care service is provided to an insured person by a care provider, etc., and the charge for such care service is charged, the local governments cannot perform the check, and more and more There was a problem that the kitchen situation of nursing care insurance finances became difficult.

  The present invention has been made in view of the above points, and an object thereof is to efficiently check the provision of inappropriate care services to an insured person.

  Therefore, in order to solve the above problem, the present invention provides a care service suitability check method in a care service suitability check device for checking the suitability of a care service, and the care service suitability check device includes the care service suitability check device. Provided to the insured person of the nursing care insurance stored in the benefit data storing means of the care service suitability check device and the authorization data related to the mental and physical state of the insured person of the nursing care insurance stored in the authorized data storage means A nursing care service suitability check stage for checking the suitability of nursing care service using benefit data relating to a nursing care service provision fee, and a check result display stage for displaying a result checked in the nursing care service suitability check stage. It is characterized by that.

  According to the present invention, there is provided a care service suitability check method in a care service suitability check device for checking the suitability of a care service, wherein the care service suitability check device is stored in the authorized data storage means of the care service suitability check device. Data related to the mental and physical condition of the insured person of the long-term care insurance and the provision fee of the long-term care service provided to the insured person of the long-term care insurance stored in the benefit data storage means of the care service suitability check device By including a care service suitability check stage for checking the suitability of the care service using the benefit data, and a check result display stage for displaying a result checked in the care service suitability check stage, for example, a survey service etc. Providing inappropriate care services to insured persons without having to It is possible to efficiently check.

  Moreover, in order to solve the said problem, this invention is good also as a care service appropriateness check program, a recording medium, and a care service appropriateness check apparatus.

  ADVANTAGE OF THE INVENTION According to this invention, provision of the inappropriate care service with respect to an insured person can be checked efficiently.

  Hereinafter, embodiments of the present invention will be described with reference to the drawings. First, an example of a hardware configuration of a care service suitability check device (or a PC (Personal Computer)) 1 is shown in FIG. FIG. 1 is a hardware configuration diagram of a care service suitability check device.

  As shown in FIG. 1, the care service appropriateness check device 1 includes, as a hardware configuration, an input unit 11, a display unit 12, a recording medium drive unit 13, a ROM (Read Only Memory) 15, and a RAM (Random). It includes an Access Memory (CPU) 16, a CPU (Central Processing Unit) 17, an interface unit 18, and an HD (Hard Disk) 19.

  The input unit 11 includes a keyboard and a mouse operated by an operator (or user) of the care service suitability check device 1 and is used to input various operation information and the like to the care service suitability check device 1. The display unit 12 includes a display used by an operator of the care service suitability check device 1 and is used to display various types of information (or screens). The interface unit 18 is an interface for connecting the care service suitability check device 1 to a network or the like. For example, in response to a request from the user via the input unit 11 or the like, the care service appropriateness check device 1 transmits data such as an appropriate check result of the care service described later to the care service appropriateness check device 1 via the network. It is sent to a connected printer or the like for printing.

  The care service suitability check program for checking the suitability of the care service is provided to the care service suitability check device 1 by the recording medium 14 such as a CD-ROM, or downloaded through a network or the like. The recording medium 14 is set in the recording medium drive unit 13, and the care service suitability check program is installed in the HD 19 from the recording medium 14 via the recording medium drive unit 13.

  The ROM 15 records a program or the like that is read first when the care service suitability check device 1 is turned on. The RAM 16 is a main memory of the care service suitability check device 1. The CPU 17 reads out a care service suitability check program from the HD 19 as necessary, stores it in the RAM 16, and executes the care service suitability check program to provide all or part of the functions described later, or to be described later. Execute flowcharts and so on. In addition to the care service appropriateness check program, the HD 19 stores, for example, later-described authorization data, benefit data, appropriate rules, and the like.

  Hereinafter, an example of a functional configuration of the care service suitability check device 1 is shown in FIG. FIG. 2 is a functional configuration diagram of the care service adequacy check device. As shown in FIG. 2, the care service adequacy check device 1 includes, as a functional configuration, an authorized data initial processing unit 21, a benefit data initial processing unit 22, an authorized error correction unit 23, a benefit error correction unit 24, Appropriate rule editing / selection unit 25, appropriate check unit 26, check result display unit 27, authorization data storage unit 31, benefit data storage unit 32, initial processed approval data storage unit, and initial processed header data Storage unit, initial processed detailed data storage unit, initial set appropriate rule storage unit 40, error corrected authorization data storage unit 33, service code conversion table storage unit 34, and conversion corrected detailed data storage unit 35 Conversion corrected total data storage unit 36, selected appropriate rule storage unit 37, insurer name master storage unit, insured person name master storage unit, and plan operator name Comprising a static storage, a service provider name master storage unit, and the check result summary data storage unit 38, and the check result item data storage unit 39, a.

  The above-described initial processed authorization data storage unit, initial processed header data storage unit, initial processed detail data storage unit, error corrected authorized data storage unit 33, service code conversion table storage unit 34, and conversion corrected detailed data Storage unit 35, conversion corrected total data storage unit 36, selected appropriate rule storage unit 37, insurer name master storage unit, insured person name master storage unit, plan operator name master storage unit, service provider name master storage Data, the check result summary data storage unit 38, the check result detailed data storage unit 39, and the like may be stored in the HD 19, the RAM 16 or the like. The same applies to data stored in other storage units described below.

  The authorized data initial processing unit 21 uses authorized data stored in the authorized data storage unit 31 or authorized data processing conditions set by the user using the processing condition setting screen 41 (see FIG. 4 described later). , Initial processing is performed to create initial processed certification data, and the initial processed certification data is stored in the initial processed certification data storage unit. The details of the authorization data initial processing in the authorization data initial processing unit 21 will be described with reference to the flowchart of FIG.

  Here, an example of the authorization data stored in the authorization data storage unit 31 is shown in FIG. FIG. 3 is a diagram showing the authorization data stored in the authorization data storage unit. Accreditation data is data when the insured determines the level of care required (not applicable, support required, 7 ranks of care required 1 to 5) in order to receive the benefits of care service of care insurance. There is one record for each insurer certification. In addition, there is a multi-month certification period for each certification, and the insured person receives benefits for nursing care services corresponding to the degree of care required (degree of care required for secondary judgment) during the certification validity period. be able to.

  As shown in FIG. 3, the certification data includes items of “insurer number”, “insured person number”, “date of certification application”, “date of birth”, “gender”, “ "Insured Name", "Primary Judgment Result", "Secondary Judgment Result", "Accreditation Validity Period Start Date", "Accreditation Validity Period End Date", "Physical Paralysis", "Contracts", "Turn over", "Wake up", "May be damaging if things are stolen", "Writing and telling others around", "Last 14 days Medical treatment received, ”“ independence of the elderly with disabilities ”, and“ independence of the elderly with dementia ”.

  The certification data includes information on the certification validity period that was established at the time of certification application. Later, due to changes in the state of mind and body, etc., to change the level of care required even during the certification validity period. Application for certification may be made. Therefore, there is a case where information on the valid period of the subsequent certification data overlaps with information on the valid period of the previous certification data. In such a case, it is necessary to remove the overlap of the certification valid periods by correcting the certification valid period information of the later certification data with the error correction as will be described later.

  An example of the processing condition setting screen 41 is shown in FIG. FIG. 4 is a diagram showing a processing condition setting screen. The user uses the processing condition setting screen 41 as shown in FIG. 4, for example, to set common processing conditions in the care service suitability check process. Further, although not shown in FIG. 2 for simplification of explanation, the care service appropriateness check device 1 is not limited to the generation unit that generates a screen as shown in FIG. Etc. may be included.

  Returning to the description of FIG. 2 again, the benefit data initial processing unit 22 performs the benefit data processing set by the user using the benefit data stored in the benefit data storage unit 32 and the screen for setting benefit data processing conditions. Initial processing is performed using conditions, etc., initial processed header data and initial processed detail data are created, initial processed header data is stored in the initial processed header data storage, and initial processed details Store the data in the initial processed detail data storage. Details of the benefit data initial processing in the benefit data initial processing unit 22 will be described with reference to the flowchart of FIG.

  Here, the benefit data is the data of nursing care services provided by the service provider according to the degree of nursing care that the insured has received, and the benefits are provided for each service provider for each insured by the examination month. There is a detail record for each service code (thousands of types of codes) of the care service received. In the detail record, the number of times the service code is used (or the number of days) and the number of service units (the unit number when the fee for one unit is about 10 yen). 1 unit charge is determined in advance in consideration of regional characteristics). Further, header information is added for each service provider for each insured person for each examination month, and there are a plurality of formats for the detailed information included in the header depending on the content of the care service.

  Hereinafter, an example of the data structure of the benefit data stored in the benefit data storage unit 32 is shown in FIG. FIG. 5 is a diagram illustrating a data configuration of benefit data stored in the benefit data storage unit. As shown in FIG. 5, the benefit data includes header information for each service provider for each insured person for each examination month, and includes a plurality of detailed information corresponding to each header information. The detailed information has a partly different format depending on the contents of the record. The benefit data is handled as one file for each insurer's examination month.

  Hereinafter, an example of data included in the header information and data included in the detail information is illustrated in FIG. FIG. 6 is a diagram illustrating data included in the header information and data included in the detailed information. As shown in FIG. 6, the header information includes, as items, “record identification information”, “creation classification”, “insurer number”, “insured person number”, “service provision month”, “Service provider number”, “Birth date”, “Gender”, “Secondary determination result”, “Accreditation valid period start date”, “Accreditation valid period end date”, “Planning company” Number ”and“ Examination month ”.

  Further, as shown in FIG. 6, the detailed information includes, as items, “record identification information”, “insurer number”, “insured person number”, “service provision month”, and “service provider”. It includes “number”, “service code”, “number of days / times”, “number of service units”, and “examination month”.

  The benefit data is the data that is processed together for each insurer every month, but the same service of the same service provider to the same insured for reasons such as incorrect billing by the service provider or fraudulent claims Multiple data may exist even during the month of provision. In this case, multiple examination months (months when the benefit data is examined) will occur. Such error data needs to be replaced with error correction as described later, for example, data of the last examination month.

  Here, FIG. 7 shows an example of the service code included in the detailed information shown in FIG. FIG. 7 is a diagram illustrating a service code. As shown in FIG. 7, the service code is represented by a 6-digit code that combines a 2-digit code (number) for identifying the service type and a 4-digit code for identifying the service type item. . FIG. 8 is a diagram showing service types.

  Returning to the description of FIG. 2 again, the certification error correction unit 23 performs the initial processing completed authorization data stored in the initial processing authorization data storage unit and the initial processing completed data stored in the initial processing header data storage unit. Using the header data or the like, the authorization error correction process is performed to create the error corrected authorization data, and the error corrected authorization data is stored in the error corrected authorization data storage unit 33. The details of the authorized error correction process in the authorized error correction unit 23 will be described with reference to the flowchart of FIG.

  Here, an example of the error corrected authorization data stored in the error corrected authorization data storage unit 33 is shown in FIG. FIG. 9 is a diagram illustrating error corrected authorization data stored in the error corrected authorization data storage unit. As shown in FIG. 9, the erroneously corrected certification data includes the following items: “Insurer number”, “Insured person number”, “Certification application date”, “Insured person name”, and “Primary determination” `` Result '', `` Secondary determination result '', `` Certification valid period start date '', `` Certification valid period end date '', `` Physical paralysis '', `` Joint contracture '', `` Roll down '', “Getting up”, “May be damaging if things are stolen”, “Making narratives and telling others”, “Medical care received in the past 14 days”, “Old people with disabilities And “independence of elderly people with dementia”.

  Returning to the description of FIG. 2 again, the benefit error correction unit 24 converts the initial processed detail data stored in the initial processed detail data storage unit and the service code conversion stored in the service code conversion table storage unit 34. Using a table, etc., the benefit error correction process is performed, conversion-corrected detailed data and conversion-corrected aggregated data are created, the conversion-corrected detailed data is stored in the conversion-corrected detailed data storage unit 35, and converted. The corrected total data is stored in the converted corrected total data storage unit 36. The details of the benefit error correction process in the benefit error correction unit 24 will be described with reference to the flowchart of FIG.

  An example of the service code conversion table stored in the service code conversion table storage unit 34 is shown in FIG. FIG. 10 is a diagram illustrating a service code conversion table stored in the service code conversion table storage unit. The service code conversion table converts the service code as shown in FIG. 7 (or indicated in the item on the first line in FIG. 10) from the item on the second line to the value for each item on the tenth line in FIG. It is a table for converting into disassembled code.

  Next, an example of the conversion-corrected detailed data stored in the conversion-corrected detailed data storage unit 35 is shown in FIG. FIG. 11 is a diagram showing the conversion-corrected detailed data stored in the conversion-corrected detailed data storage unit. As shown in FIG. 11, the conversion-corrected detailed data includes “insurer number”, “insured person number”, “gender”, “age”, and “service provision month” as items. , “Service Provider Number”, “Planned Operator Number”, “Service Type”, “Rehabilitation Support”, “Dementia Support”, “Time Required”, “Additional Staff”, “Main Unit” And “Separate line”, “Addition category”, “Subtraction category”, “Service category”, “Days / times”, “Number of service units”, and “Review month”.

  An example of the converted and corrected total data stored in the conversion / corrected total data storage unit 36 is shown in FIG. FIG. 12 is a diagram illustrating the conversion-corrected total data stored in the conversion-corrected total data storage unit. As shown in FIG. 12, the converted and corrected total data includes items of “insurer number”, “insured person number”, “gender”, “age”, and “service provision month”. , “Service Provider Number”, “Planned Operator Number”, “Service Type”, “Rehabilitation Response”, “Dementia Response”, “Time Required”, “Additional Staff”, “Days”・ Includes “Number of times”, “Number of service units”, and “Judgment month”.

  Returning to the description of FIG. 2 again, the appropriate rule editing / selecting unit 25 selects an initial set appropriate rule stored in the initial set appropriate rule storage unit, for example, an appropriate rule selection screen 42 and / or an appropriate rule described later. In response to a request from the content display screen 43 and / or the appropriate rule editing screen 44, etc., editing and / or selection is performed, and the selected appropriate rule is stored in the selected appropriate rule storage unit 37. Details of the appropriate rule editing / selecting process in the appropriate rule editing / selecting unit 25 will be described with reference to a flowchart of FIG.

  Here, an example of the initially set rules stored in the initially set appropriate rule storage unit 40 is shown in FIG. FIG. 13 is a diagram illustrating the initially set rules stored in the initially set appropriate rule storage unit. As shown in FIG. 13, the initial set appropriate rules include, as items, “rule serial number”, “warning level”, “warning category”, “mental and physical condition”, “warning content”, “ “First item”, “first code”, “value of first item”,... “Nth item”, “nth code”, “ the value of the nth item ”. As shown in FIG. 13, n (n is a natural number of 1 or more) conditions can be set for one appropriate rule (selected appropriate rule). When a plurality of conditions are set in the appropriate rule, these are AND conditions. For example, as an example of an appropriate rule, “Warning level: 1 (highest degree), warning classification: 17 (welfare equipment provided), psychosomatic state level: 1 (mild), warning content: walking is independent and a cane is provided, one Eye item: Walking, 1st code: = 1st item value: Independence, 2nd item: Number of service units of wand with welfare equipment, 2nd code:> 2nd Is stored in the initial set appropriate rule storage unit 40. In addition to the initial set rule, the initial set appropriate rule storage unit 40 can be edited by the user using, for example, an appropriate rule content display screen 43 described later, an appropriate rule edit screen 44, and the like. The rules that strengthened the visiting services and the rules that strengthened the commuting services are also stored.

  Next, an example of the selected appropriate rule stored in the selected appropriate rule storage unit 37 is shown in FIG. FIG. 14 is a diagram illustrating selected appropriate rules stored in the selected appropriate rule storage unit. As described above, the selected appropriate rule storage unit 37 stores the appropriate rule edited and / or selected by the user or the like as the selected appropriate rule.

  An example of the appropriate rule selection screen 42 is shown in FIG. FIG. 15 is a diagram showing an appropriate rule selection screen. For example, the user uses the appropriate rule selection screen 42 as shown in FIG. 15 to select an appropriate rule from the initially set appropriate rule storage unit 40 via the appropriate rule editing / selection unit 25 or the like.

  An example of the appropriate rule content display screen 43 is shown in FIG. FIG. 16 is a diagram showing an appropriate rule content display screen. For example, the user uses the appropriate rule content display screen 43 as shown in FIG. 16 to display the content of the appropriate rule selected using the appropriate rule selection screen 42 in FIG.

  An example of the appropriate rule editing screen 44 is shown in FIG. FIG. 17 is a diagram showing an appropriate rule editing screen. For example, the user edits the content of the appropriate rule displayed using the appropriate rule content display screen 43 of FIG. 16 using the appropriate rule editing screen 44 as shown in FIG.

  Returning to the description of FIG. 2 again, the appropriateness check unit 26 uses, for example, the conditions specified by the user on the processing condition setting screen 41 shown in FIG. When the user confirms the insurer or the service provision month and receives information that the execution button or the like has been pressed, the error corrected authorization data stored in the error correction authorization data storage unit 33 and the conversion correction Conversion corrected detail data stored in the completed detail data storage unit 35, conversion corrected aggregation data stored in the conversion corrected aggregation data storage unit 36, and selected appropriate rule storage unit 37 Check the appropriateness of the nursing care service using the selected appropriate rule and create check result summary data and check result detailed data as check results. Click Results stores summary data check result in the summary data storage unit 38, and stores the check results detailed data check result to the detailed data storage section 39. In addition, the appropriateness check unit 26 displays the execution result of the appropriate tick process on the appropriateness check screen 45. In addition, the appropriateness check part 26 is the insured person name stored in the insured person name master storage part and the insured person name master storage part stored in the insurer name master storage part. Using the master, the plan operator name master stored in the plan operator name master storage unit, and the service provider name master stored in the service provider name master storage unit, check result detailed data create. However, details of the appropriateness check process in the appropriateness check unit 26 will be described with reference to a flowchart of FIG. 29 described later.

  An example of the check result summary data stored in the check result summary data storage unit 38 is shown in FIG. FIG. 18 is a diagram illustrating check result summary data stored in the check result summary data storage unit. As shown in FIG. 18, the check result summary data includes “summary item”, “number”, and “number of cases” as items.

  Next, an example of the check result detailed data stored in the check result detailed data storage unit 39 is shown in FIG. FIG. 19 is a diagram illustrating the check result detailed data stored in the check result detailed data storage unit. As shown in FIG. 19, the check result summary data includes, as items, “result serial number”, “insured person number”, “insured person name”, “secondary determination”, and “gender”. , “Age”, “plan provider number”, “plan provider name”, “service provider number”, “service provider name”, “service provision month”, “examination month” ”,“ Service type ”,“ Rehabilitation response ”,“ Dementia response ”,“ Time required ”,“ Additional staff ”,“ Separate from main unit ”,“ Addition category ”,“ Subtraction ” "Classification", "Service type classification", "Rule sequence number", "Warning level", "Warning classification", "Mental and physical condition", and "Warning content".

  An example of the appropriateness check screen 45 is shown in FIG. FIG. 20 is a diagram showing an appropriateness check screen. As described above, for example, the user confirms the insurer and the service provision month on the appropriateness check screen 45 and presses the execution button to check the appropriateness of the care service, for example, the appropriateness check unit 26 and the like. To request. Moreover, the appropriateness check screen 45 displays the execution result of the appropriateness check process of the care service performed by the appropriateness check unit 26, for example.

  2 again, when the check result display unit 27 receives information indicating that the result summary confirmation button has been pressed by the user or the like on the appropriateness check screen 45 shown in FIG. 20, for example, the check result summary data The check result summary data stored in the storage unit 38 is used to create and display a proper check result summary screen 46 as shown in FIG.

  FIG. 21 is a diagram showing an appropriate check result summary screen. An appropriate check result summary screen 46 shown in FIG. 21 shows an example in which a service provider tag is selected. For example, when the check result display unit 27 receives information indicating that the extraction condition setting button has been clicked on the appropriate check result summary screen 46 as shown in FIG. 47 is created and displayed.

  FIG. 22 is a diagram showing a check result extraction condition setting screen. For example, the check result display unit 27 and the like indicate that the user has selected (or entered) the check result extraction condition on the check result extraction condition setting screen 47 as shown in FIG. When the information is received, the check result detailed data stored in the check result detailed data storage unit 39 is acquired based on the check result extraction condition, and the acquired check result detailed data is shown in FIG. The appropriate check details screen 48 is created and displayed.

  FIG. 23 is a diagram showing an appropriate check details screen. As shown in FIG. 23, on the appropriate check details screen 48, check result details data that matches the extraction conditions set on the check result extraction condition setting screen 47 is displayed. Details of the check result display process in the check result display unit 27 will be described with reference to a flowchart of FIG.

  An example of authorized data initial processing in the authorized data initial processing unit 21 is shown in FIG. FIG. 24 is a flowchart showing the authorized data initial processing in the authorized data initial processing unit. Note that the solid line shown in the flowchart of FIG. 24 indicates the flow of data. The same applies to the following flowcharts.

  In step S <b> 10, the authorized data initial processing unit 21 conforms to a plurality of authorized data file names designated by the user or the like as authorized data processing conditions and the processing conditions set by the user using the processing condition setting screen 41. The certification data is acquired from the certification data storage unit 31, the condition conformity certification data is created, and stored in the condition conformance certification data storage unit. In the process of step S10, the authorized data initial processing unit 21 discards, for example, authorized data that does not have psychosomatic information, and creates authorized data (condition-qualified authorized data) including only data items used in this system.

  In step S11, the certification data initial processing unit 21 converts the condition conformity certification data into an insurer number, an insured number, a certification application date, and an auxiliary key (sequential number when there are multiple applications within the same application date). Sorted in ascending order, rearranged certified data is created and stored in the sorted certified data storage unit.

  In step S12, the authorized data initial processing unit 21 deletes duplicate data from the rearranged authorized data, creates initial processed authorized data, and stores it in the initially processed authorized data storage unit. For example, if the authorization data initial processing unit 21 has the authorization data on the same certification application date (sorted certification data) of the same insured number among the sorted certification data, the last certification data (sorted) Duplicate data is deleted by adopting certified data.

  An example of benefit data initial processing in the benefit data initial processing unit 22 is shown in FIG. FIG. 25 is a flowchart showing benefit data initial processing in the benefit data initial processing unit. In step S20, the benefit data initial processing unit 22 conforms to a plurality of benefit data file names specified by the user or the like as the benefit data processing conditions and the processing conditions set by the user using the processing condition setting screen 41, for example. The benefit data is acquired from the benefit data storage unit 32, the condition conforming header data and the condition conforming detailed data are created, the condition conforming header data is stored in the condition conforming header data storing unit, and the condition conforming detailed data is defined as the condition conforming header data. Store in the relevant detail data storage.

  In step S21, the benefit data initial processing unit 22 sets the condition conforming header data in the ascending order of the insurer number, the insured number, the service provision month, the service provider, the examination month, and the creation category (new, modified, canceled). The rearranged and rearranged header data is created and stored in the rearranged header data storage unit.

  In step S22, the benefit data initial processing unit 22 rearranges the condition conforming detailed data in ascending order of the insurer number, the insured number, the service provision month, the service provider, the service code, the examination month, and the creation category. The initial processed detail data is created and stored in the initial processed detail data storage unit.

  In step S23, the benefit data initial processing unit 22 deletes duplicate data from the rearranged header data, creates initial processed header data, and stores it in the initial processed header data storage unit. For example, if there is header data (reordered header data) of the same service provision month with the same insured number among the rearranged header data, the benefit data initial processing unit 22 determines the last header data (reordered By adopting (header data), duplicate data is deleted.

  An example of the authorized error correction process in the authorized error correction unit 23 is shown in FIG. FIG. 26 is a flowchart showing a certification error correction process in the certification error correction unit. In step S30, the certification error correction unit 23 sorts and sorts the initial processed certification data in ascending order of the insurer number, the insured person number, the certification validity period start date, the certification validity period end date, and the certification application date. Finished approval data is created and stored in the sorted authorization data storage unit.

  On the other hand, in step S31, the certification error correction unit 23 sets the initial processed header data in ascending order of the insurer number, the insured number, the certification valid period start date, the certification valid period end date, the service provision month, and the examination month. The rearranged and rearranged header data is created and stored in the rearranged header data storage unit.

  In step S32, the authorization error correction unit 23 removes the overlap, creates the overlap-removed authorization data when the authorization validity period for each insured person overlaps in the sorted authorization data, and removes the overlap. Stored in the completed authorization data storage. For example, the accreditation error correction unit 23 adopts the later data if the overlapping accreditation valid period is within the same period, and if the period is different, the accreditation error correction unit 23 uses the end date of the previous period as the start date of the later period. The overlap is removed by replacing the previous day.

  In step S33, the authorization error correction unit 23 removes the overlap in the same way as in step S32 when the authorization valid period for each insured person overlaps in the sorted header data, and the overlap removed header data is obtained. Create and store in the overlap removed header data storage.

  In step S <b> 34, the authorization error correction unit 23 collates (integrates) the authorization data with the same insured person whose certification validity period overlaps, and creates error correction authorization data. Note that the certification error correction unit 23 uses the header data side with high accuracy and matches the secondary determination result and the certification validity period. In addition, when a plurality of certification data is collated with one header data, the certification error correction unit 23 creates error correction certification data for the number of certification data matched. In such a case, the certification error correction unit 23 divides the validity period of the header data by the certification validity period start date of the second and subsequent certification data, thereby making a plurality of matches utilizing the mental and physical state information of a plurality of certification information. Create information.

  As shown in step S34 of FIG. 26, the certification error correction unit 23 adopts the header data side (that is, the benefit data side) with high accuracy for the secondary determination result and the certification validity period, and certification. By correcting the data, it is possible to create authorized data (error-corrected authorized data) without error.

  Hereinafter, an example of the benefit error correction process in the benefit error correction unit 24 is shown in FIG. FIG. 27 is a flowchart showing a benefit error correction process in the benefit error correction unit. In step S40, the benefit error correction unit 24 sets the data whose final creation category is not canceled for each insurer number, insured number, service provision month, service provider, and service code in the initial processed detailed data. By adopting, error correction is performed, error corrected detail data is created, and stored in the error correction detail data storage unit.

  In step S41, the benefit error correction unit 24 stores the service code included in the error correction detail data stored in the error correction detail data storage unit in the service code conversion table storage unit 34. In accordance with the code conversion table, the code is converted into a meaningful code in the appropriateness check process, code-converted detailed data including the converted code is created, and stored in the code-converted detailed data storage unit. Here, the reason for converting the service code is that the service code is the service type (visiting care, visiting bath, visiting nursing, visiting rehabilitation, visiting care, visiting rehabilitation, etc.) number and item for each service type (in the case of visiting care) The type of care, the length of the provision time, the qualification of the visitor, the number of visitors, the visit time zone, etc.), and the types are enormous.

  In step S42, the benefit error correction unit 24 converts the code-converted detailed data into the insurer number, the insured number, the service provision month, the service provider, the converted code (service type, rehabilitation support, dementia, etc.). Sort) in ascending order of code), create rearranged detail data, and store in the rearranged detail data storage unit.

  In step S43, the payment error correction unit 24 aggregates the sorted detailed data for each insurer number, insured number, service provision month, service provider, and converted code (number of days / number of times, number of service units). Then, the conversion-corrected detailed data is created and stored in the conversion-corrected detailed data storage unit 35, and the rearranged detailed data is converted into the insurer number, the insured number, the service provision month, the service provider, and the service. Aggregation is performed for each type, and conversion-corrected aggregate data is created and stored in the conversion-corrected aggregate data storage unit 36. Note that the conversion-corrected detailed data stored in the conversion-corrected detailed data storage unit 35 shown in FIG. 11 described above is an example of the conversion-corrected detailed data after the processing in step S43 is completed.

  As shown in step S41 of FIG. 27, by converting the service code included in the error-corrected detailed data into a meaningful code in the appropriateness check process, an appropriate appropriateness check process can be performed, and the user Can be made easy to see and understand.

  Hereinafter, an example of the appropriate rule editing / selecting process in the appropriate rule editing / selecting unit 25 is shown in FIG. FIG. 28 is a flowchart showing appropriate rule editing / selection processing in the appropriate rule editing / selection unit. In step S50, the appropriate rule editing / selecting unit 25, as described above, for example, sets the initially set appropriate rule in response to a request from the appropriate rule selection screen 42, the appropriate rule content display screen 43, the appropriate rule edit screen 44, and the like. Edited or added (additional correction) or deletion (hereinafter, simply described as an example of additional correction), etc., and the additionally corrected appropriate rule is stored in the additional corrected appropriate rule storage unit. Note that a plurality of additional corrected appropriate rules that have been additionally corrected may be stored in the additional corrected appropriate rule storage unit. In addition, the appropriate rule editing / selecting unit 25 may further add and correct the additional corrected appropriate rule stored in the additional corrected appropriate rule storage unit and store the additional corrected appropriate rule storage unit in the additional corrected appropriate rule storage unit.

  In step S51, the appropriate rule editing / selecting unit 25 selects an appropriate rule in response to a request from the above-described appropriate rule selection screen 42, creates a selected appropriate rule, and stores it in the selected appropriate rule storage unit 37. Store.

  As shown in FIG. 28, the appropriate rule editing / selecting unit 25 receives the initial set appropriate rule stored in the initial set appropriate rule storage unit 40 in response to a request from the user via the screen or the like. By selecting, editing, or additional correction, for example, it is possible to generate and store appropriate rules that take into account the characteristics of the care provider for each local government where the care service appropriateness check device 1 is installed, regional characteristics, etc. it can.

  Hereinafter, an example of the appropriateness check process of the care service in the appropriateness check unit 26 is shown in FIG. FIG. 29 is a diagram illustrating the appropriateness check process of the care service in the appropriateness check unit. In step S60, the appropriateness check unit 26 first reads out the selected appropriate rule from the selected appropriate rule storage unit 37, and then matches the error corrected authorization data for each error corrected detail data item. The selected appropriate rule is checked for each data.

  The appropriateness check unit 26 writes together the selected adequacy rules corresponding to the selected adequacy rules as many as the number of cases matched, and stores them in the check result detailed data storage unit 39 as check result detailed data. When the appropriateness check unit 26 stores the check result detailed data in the check result detailed data storage unit 39, the insurer number, the insured number, the planned business operator number, and the service business operator number are stored in each name master. If data exists, store it with a name. Similarly, the appropriateness check unit 26 matches erroneously corrected certified data with erroneously corrected total data, checks the selected appropriate rule for each of the input data, and matches the selected correct rule. Are stored together in the check result detailed data storage unit 39 as the check result detailed data, as many as the selected appropriate rules.

  In addition, the appropriateness check unit 26 counts the number of check result detailed data for each plan operator, each service operator, each warning level, each warning category, and each mental and physical state, and creates check result summary data. And stored in the check result summary data storage unit 38.

  As shown in FIG. 29, the appropriateness check unit 26 compares the authorization data with the benefit data using the selected appropriate rule, and checks the appropriateness of the care service, for example, to perform a survey operation or the like. Therefore, it is possible to efficiently check the provision of inappropriate care services to the insured.

  An example of the check result display process in the check result display unit 27 is shown in FIG. FIG. 30 is a flowchart of the check result display process in the check result display unit. In step S70, when the check result display unit 27 receives information indicating that the result summary confirmation button has been pressed by the user or the like on the appropriateness check screen 45 as shown in FIG. 20, for example, the check result summary data is stored. Using the check result summary data stored in the unit 38, the above-described appropriate check result summary screen 46 as shown in FIG. 21 is created and displayed.

  When the check result display unit 27 receives information indicating that the extraction condition setting button has been clicked on the appropriate check result summary screen 46 shown in FIG. 21, for example, as shown in FIG. A check result extraction condition setting screen 47 as shown is created and displayed.

  In step S71, the check result display unit 27 selects (or inputs) the check result extraction condition and the like on the check result extraction condition setting screen 47 as shown in FIG. Upon receipt of the information indicating that the check result is extracted, the check result detailed data stored in the check result detailed data storage unit 39 is acquired based on the check result extraction condition, and the check result detailed data is used to obtain the above-described check result detailed data. A proper check details screen 48 as shown in FIG. 23 is created and displayed.

  As described above, according to the present embodiment, it is possible to efficiently check the provision of inappropriate care services to the insured.

  The preferred embodiments of the present invention have been described in detail above, but the present invention is not limited to such specific embodiments, and various modifications can be made within the scope of the gist of the present invention described in the claims.・ Change is possible.

FIG. 1 is a hardware configuration diagram of a care service suitability check device. FIG. 2 is a functional configuration diagram of the care service adequacy check device. FIG. 3 is a diagram showing the authorization data stored in the authorization data storage unit. FIG. 4 is a diagram showing a processing condition setting screen. FIG. 5 is a diagram illustrating a data configuration of benefit data stored in the benefit data storage unit. FIG. 6 is a diagram illustrating data included in the header information and data included in the detailed information. FIG. 7 is a diagram illustrating a service code. FIG. 8 is a diagram showing service types. FIG. 9 is a diagram illustrating error corrected authorization data stored in the error corrected authorization data storage unit. FIG. 10 is a diagram illustrating a service code conversion table stored in the service code conversion table storage unit. FIG. 11 is a diagram illustrating erroneously corrected detailed data stored in the conversion / corrected detailed data storage unit. FIG. 12 is a diagram illustrating error corrected total data stored in the conversion corrected total data storage unit. FIG. 13 is a diagram illustrating the initially set rules stored in the initially set appropriate rule storage unit. FIG. 14 is a diagram illustrating selected appropriate rules stored in the selected appropriate rule storage unit. FIG. 15 is a diagram showing an appropriate rule selection screen. FIG. 16 is a diagram showing an appropriate rule content display screen. FIG. 17 is a diagram showing an appropriate rule editing screen. FIG. 18 is a diagram illustrating check result summary data stored in the check result summary data storage unit. FIG. 19 is a diagram illustrating the check result detailed data stored in the check result detailed data storage unit. FIG. 20 is a diagram showing an appropriateness check screen. FIG. 21 is a diagram showing an appropriate check result summary screen. FIG. 22 is a diagram showing a check result extraction condition setting screen. FIG. 23 is a diagram showing an appropriate check details screen. FIG. 24 is a flowchart showing the authorized data initial processing in the authorized data initial processing unit. FIG. 25 is a flowchart showing benefit data initial processing in the benefit data initial processing unit. FIG. 26 is a flowchart showing a certification error correction process in the certification error correction unit. FIG. 27 is a flowchart showing a benefit error correction process in the benefit error correction unit. FIG. 28 is a flowchart showing appropriate rule editing / selection processing in the appropriate rule editing / selection unit. FIG. 29 is a diagram illustrating the appropriateness check process of the care service in the appropriateness check unit. FIG. 30 is a flowchart of the check result display process in the check result display unit.

Explanation of symbols

DESCRIPTION OF SYMBOLS 1 Care service appropriateness check apparatus 11 Input part 12 Display part 13 Recording medium drive part 14 Recording medium 15 ROM
16 RAM
17 CPU
18 Interface unit 19 HD
21 Certification Data Initial Processing Unit 22 Benefit Data Initial Processing Unit 23 Certification Error Correction Unit 24 Benefit Error Correction Unit 25 Appropriate Rule Editing / Selection Unit 26 Appropriate Check Unit 27 Check Result Display Unit 31 Accreditation Data Storage Unit 32 Benefit Data Storage Unit 33 Error Modified authorized data storage unit 34 Service code conversion table storage unit 35 Conversion corrected detailed data storage unit 36 Conversion corrected total data storage unit 37 Selected appropriate rule storage unit 38 Check result summary data storage unit 39 Check result detailed data storage unit 40 Initialized appropriate rule storage unit 41 Processing condition setting screen 42 Appropriate rule selection screen 43 Appropriate rule content display screen 44 Appropriate rule edit screen 45 Appropriate check screen 46 Appropriate check result summary screen 47 Check result extraction condition setting screen 48 Appropriate check details screen

Claims (8)

A care service adequacy check method in a care service adequacy check device for checking adequacy of care service,
The care service suitability check device is
The certification data relating to the mental and physical state of the insured person of the long-term care insurance stored in the certification data storage means of the long-term care service appropriate check device and the long-term care insurance stored in the benefit data storage means of the long-term care service appropriate check device Nursing service adequacy check stage that checks the adequacy of the nursing care service using the benefit data related to the provision fee of the nursing care service provided to the insured person,
A check result display stage for displaying a result of checking in the care service suitability check stage;
A care service adequacy check method characterized by including:   In the care service suitability check stage, the care service suitability check device is based on the rule data for checking the suitability of the care service stored in the rule information storage means of the care service suitability check device, The method of checking the appropriateness of care service according to claim 1, wherein the appropriateness of care service is checked using the benefit data.   3. The care service suitability check method according to claim 2, further comprising a rule information editing / selection step in which the care service suitability check device edits or selects rule information stored in the rule information storage means. The care service suitability check device further includes a nursing care certification correction step of correcting the certification data using the benefit data,
4. In the care service suitability check stage, the care service suitability check device checks the suitability of the care service using the certification data modified in the care certification certification modification stage. The care service adequacy check method according to claim 1. The benefit data includes a service code indicating a type of care service provided to an insured person of long-term care insurance, and an item for each service type,
The care service suitability check device further includes a service code conversion step of converting the service code into a code meaningful for checking the suitability of the care service,
5. The care service adequacy check stage, wherein the care service adequacy check device checks the adequacy of the care service using benefit data including the code converted in the service code conversion stage. The care service adequacy check method according to any one of the preceding claims.   6. A care service suitability check program that causes the care service suitability check device to execute the care service suitability check method according to any one of claims 1 to 5.   A recording medium readable by the care service adequacy check device, wherein the care service adequacy check program according to claim 6 is recorded. A care service appropriateness check device for checking the appropriateness of care service,
Authorized data storage means for storing authorized data relating to the mental and physical state of the insured person of the long-term care insurance;
Benefit data storage means for storing benefit data related to the provision fee of the nursing care service provided to the insured of the nursing care insurance,
Nursing service adequacy check means for checking adequacy of nursing service using the authorization data and the benefit data;
A check result display means for displaying a result checked by the care service suitability check means;
A care service adequacy check device characterized by comprising:

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