JP2023109284A - Insurance payment system, information processing method and program - Google Patents

Abstract

To allow a user to easily know a possibility to pay an insurance claim.SOLUTION: An insurance payment system according to one aspect of the present technology acquires identification information associated with a My Number (the Social Security and Tax Number) of an insured person and medical information representing details of treatment performed on the insured person, and reads out information relating to payment criteria of an insurance which the insured person subscribes to, based on one or more insurance subscription numbers associated with the identification information. The insurance payment system determines whether or not there is a possibility to pay an insurance claim based on the medical information and the payment criteria, and sends a notice to a recipient associated with the identification information that there is the possibility to pay the insurance claim if it is determined that there is the possibility to pay the insurance claim. This technology can be applied to a system used by insurance subscribers and insurance companies.SELECTED DRAWING: Figure 2

Description

The present technology particularly relates to an insurance payment system, an information processing method, and a program that enable a user to easily know that there is a possibility of payment of an insurance claim.

In order to receive insurance money for life insurance or medical insurance, it is necessary for the insured person or a relative of the insured person to apply to the insurance company to the effect that the insurance will be applied.

For example, when applying for insurance coverage, an applicant fills out an application template prepared by the insurance company in advance, creates an application form, and submits the application form and supporting documents (such as a certificate from a medical institution) to the insurance company. ), etc. The insurance company conducts an examination based on the documents submitted by the insured person, and pays the insurance money after confirming that it corresponds to the reason for payment of the insurance money.

Insurance companies go to great lengths to prevent payment omissions. Therefore, various systems have been proposed as systems for preventing payment omissions (Patent Document 1).

Japanese Unexamined Patent Application Publication No. 2013-3750

Claims for insurance claims are often made immediately after an unfortunate event for the policyholder or the policyholder's relatives. Applying in such conditions can be physically or mentally difficult.

The present technology has been developed in view of such circumstances, and enables a user to easily know that there is a possibility of payment of an insurance claim.

An insurance payment system according to one aspect of the present technology includes an acquisition unit that acquires identification information linked to an insured person's My Number and medical information that indicates details of treatment received by the insured person; a reading unit that reads out information regarding the payment criteria of the insurance that the insured person subscribes to based on one or more insurance subscription numbers linked to the information; a determination unit that determines based on the information and the payment criteria; and, if it is determined that there is a possibility of payment of the insurance money, payment of the insurance money to the first destination linked to the identification information. and a recommendation unit that transmits a notification of the possibility.

In one aspect of the present technology, identification information linked to the insured person's My Number and medical information indicating details of treatment received by the insured person are acquired, and linked to the identification information. Based on one or more policy numbers, information regarding the payment criteria of the policy subscribed by the insured person is retrieved. In addition, whether or not there is a possibility of payment of insurance is determined based on the medical information and the payment criteria, and if it is determined that there is a possibility of payment of insurance, it is associated with the identification information. A notice of the possibility of insurance payment is sent to the specified destination.

1 is a diagram illustrating an example user of an insurance payment platform implemented by an information processing system according to an embodiment of the present technology; FIG. FIG. 4 is a diagram showing the overall flow of information provision by an insurance payment platform; FIG. 2 illustrates an example of interaction between an insurance company and a user; It is a figure which shows the relationship between my number and an insurance subscription number. It is a figure which shows the flow of advance preparation. It is a figure which shows the example of subscriber management information. FIG. 4 is a diagram showing the flow of processing from when a user visits a medical institution to when he or she confirms health insurance qualification information; It is a figure which shows the example of a consent confirmation screen. FIG. 3 is a diagram showing an example of credential information provided to a medical institution; FIG. 10 is a diagram showing the flow of processing from confirmation of qualification information to transmission of an insurance payment receipt recommendation; FIG. 10 is a diagram showing an example of an insurance money receipt recommendation; It is a figure which shows the example of an intention confirmation screen. 4 is a block diagram showing a configuration example of a PF management server; FIG. 3 is a block diagram showing a functional configuration example of a PF management server; FIG. FIG. 10 is a flowchart describing processing of a PF management server; FIG. FIG. 2 is a diagram showing an example of a blockchain database; FIG. 4 is a diagram showing an example of transaction data; FIG. 4 is a diagram showing an example of transaction data; FIG. 4 is a diagram showing an example of an inference model;

Embodiments for implementing the present technology will be described below. The explanation is given in the following order.
1. About the insurance payment platform 2 . Advance preparation 3. Overall processing flow 4 . Configuration and operation of PF management server 5 . Modification

<About insurance payment platform>
FIG. 1 is a diagram illustrating an example of a user of an insurance payment platform implemented by an information processing system according to an embodiment of the present technology;

As shown in Figure 1, medical institutions, insurance companies and users are the main users of the insurance payment platform. Although two medical institutions and two insurance companies are shown in the example of FIG. 1, many more medical institutions and insurance companies are users of the insurance payment platform.

Medical institutions are hospitals, clinics, health care facilities for the elderly, pharmacies that dispense medications, and other facilities that provide medical care, as stipulated by the law on medical care. A medical institution is, for example, an institution that supports insurance medical treatment using health insurance prescribed by the Health Insurance Law.

An insurance company is a company that sells insurance products, such as life insurance, medical insurance, fire insurance, etc., including contracts that pay insurance benefits when the insured person receives medical treatment. In the following, an example of an insurance product targeting insurance medical treatment will be described, but it may also target private medical treatment.

A user, as shown at the bottom of FIG. 1, is a subscriber to insurance sold by an insurance company. The user becomes an insured person with respect to the insurance company, which is the insurer. Also, a user becomes a patient when receiving medical treatment at a medical institution. Where appropriate, users may be referred to simply as users or as policyholders. In addition, it may be explained as an insured person or as a patient.

The insurance payment platform is a system that provides various services such as presenting insurance-related information to the user and the insurance company when the user receives medical treatment covered by insurance as a patient.

FIG. 2 is a diagram showing the overall flow of information provision by the insurance payment platform.

Various functions of the insurance payment platform are implemented by a PF (platform) management server 1, which is an information processing device on the Internet. The PF management server 1 is configured by one computer or by a plurality of computers working together.

Processing for realizing the functions of the insurance payment platform will be described below as processing performed by the PF management server 1. FIG. The processing of medical institutions and insurance companies is basically performed by their respective business management systems.

The PF management server 1 has an insurance subscriber DB2, which is a database of subscriber management information, which is information on insurance subscribers. The subscriber management information includes information on insurance that each user subscribes to as an insurance subscriber, each user's My Number, and information such as the destination of notification from the insurance payment platform side. My number is a social security and tax number determined by a government agency. An example using My Number will be described below. If the identifier is associated with a health insurance card or has the function of a health insurance card and is set for each individual, the identifier may be used instead of the My Number.

As indicated by arrow A1, a user visits a medical institution and presents his or her My Number card at the counter. Card readers for reading My Number cards are installed at the counters of medical institutions. The user can receive insurance medical treatment by performing the reception using the My Number card. A device having functions equivalent to those of the My Number Card may be used instead of the My Number Card. For example, an application in which my number is set may be used.

In other words, the insurance payment platform is a system that is based on the premise that the My Number is linked to the health insurance card. Instead of the health insurance card, the user will receive medical treatment after completing the reception using the My Number card.

After the My Number card is presented, the health insurance eligibility is verified. Details of the series of processes will be described later.

When medical care is completed, medical care information is created at the medical institution. The medical information is information including information indicating the details of medical care, such as a medical bill (medical fee statement) or a medical receipt. As the medical information, an example using a receipt will be described below. A receipt is a statement describing details of treatment performed on a patient, etc., in order for the medical institution to bill the health insurance association for medical expenses. The receipt is generated as electronic information at the terminal of the medical institution. In addition, when using the receipt, medical treatment covered by health insurance is covered, but other medical information may be used to cover free medical treatment. For example, information generated by describing the contents of medical care in a format in which the medical institution can describe the contents of medical care covered by health insurance and private medical care may be used as the medical care information. At this time, the details of medical care covered by health insurance may be automatically entered based on the receipt.

A medical institution provides the PF management server 1 with a receipt as indicated by an arrow A2. As will be described later, the receipt is provided to the insurance payment platform when the user agrees to provide the receipt.

The PF management server 1 refers to the subscriber management information stored in the insurance subscriber DB 2 and identifies the insurance that the user has subscribed to. The PF management server 1 determines whether or not there is a possibility of payment of an insurance claim based on the receipt and the payment criteria of the insurance that the user subscribes to.

If it is determined that there is a possibility of payment of the insurance claim, the PF management server 1 sends a notice to the user that there is a possibility of payment of the insurance claim, as indicated by an arrow A3. Notifications to users are made using various means such as e-mail and SNS messages.

Hereinafter, the notification that there is a possibility of insurance payment is referred to as an insurance payment receipt recommendation in the sense of a notification that recommends the user to receive the insurance payment.

Further, when the user agrees to provide the insurance claim to the insurance company that is the insurer, the PF management server 1 provides the claim and shares it with the insurance company, as indicated by an arrow A4. do.

Is it correct that the insurance company that shares the insurance claim with the insurance payment platform compares the content of the claim with the content of the insurance that the user subscribes to, and determines that there is a possibility of payment of the insurance claim? confirm whether or not If the determination that the insurance claim is payable is correct, the insurance company contacts the user and guides the user on required documents, etc., as indicated by the arrow A4 in FIG.

When it becomes possible to pay an insurance claim by receiving the required documents from the user, etc., the insurance company pays the insurance claim to the user as indicated by an arrow A5.

In this way, in the insurance payment platform, communication regarding payment of insurance benefits when a user receives medical treatment covered by insurance is triggered by a notification from the insurance payment platform side (PF management server 1 side).

The conventional flow for an insurance subscriber who has received medical treatment covered by insurance to receive insurance payments is as follows.
・Insurance subscribers should remember the contents of their life insurance, medical insurance, and fire insurance (group credit insurance) after receiving medical treatment, and their medical certificate issued by the medical institution. Determine whether you can receive insurance payments for your illness (disease name). When it is determined that the insurance money can be paid, the insured person makes an inquiry to the insurance company.
・The insurance company explains the submitted documents to the insured person, and conducts an examination based on the documents (certificates from medical institutions, etc.) submitted by the insured person. An insurance company pays an insurance claim when the insured person's illness falls under the reason for payment.

In this way, in the conventional flow of payment of insurance claims for voluntary insurance, the insurance company may know the state of the insured person if the insured person, who is the patient, does not take action. Can not.

In addition, when it is necessary for the insured person to apply to the insurance company, it is often difficult to consider applying after suffering from a serious illness or after surgery. .

As described above, the interaction regarding the payment of insurance benefits when receiving medical treatment is triggered by a notification from the insurance payment platform side, so that the user does not have to know the details of his or her insurance. It is easy to know that there is a possibility of payment of insurance claims. It is possible for the user to prevent omission of the application for payment of the insurance money without applying for it himself/herself.

In addition, the insurance company can contact the user and start communication regarding insurance payment without waiting for the user's application for insurance payment. The insurance company can prevent failure to pay insurance claims.

<Advance preparation>
In order for the user to receive the insurance payment receipt recommendation, the user's My Number and the insurance subscription number must be linked as shown in FIG.

The policy number is the identification of the policyholder issued by the insurance payment platform. A policy number is issued to each user.

Processing for linking My Number and insurance enrollment number is performed as a preparatory processing.

FIG. 5 is a diagram showing the flow of preparation.

An insurance subscription number is issued to the user, as indicated by an arrow A11. The insurance subscription number is issued by the PF management server 1, for example, when the user registers as a user of the insurance payment platform.

A user who has been issued an insurance subscription number, when subscribing to optional insurance such as life insurance and medical insurance sold by an insurance company, sends user information to the insurance payment platform via the insurance company as shown by arrow A12. to notify.

User information includes user ID, password, name, my number, destination, and insurance ID.

The user ID is, for example, identification information set when registering as a user of the insurance payment platform. The user ID is identification information different from the insurance subscription number described above.

The password is the password used to use the services of the insurance payment platform. A site on the Internet is provided for using the services of the insurance payment platform. A user can use the services of the insurance payment platform by logging in to a site on the Internet using a user ID and password.

The name is the name of the user.

My Number is the user's My Number.

The destination is the destination of insurance payment platform notifications, such as insurance claim receipt recommendations. For example, the user's email address is set as the destination. A user registers a destination of a notification such as an insurance payment receipt recommendation.

The insurance ID is identification information of the insurance subscribed by the user. An ID is assigned to each insurance product of each insurance company.

The PF management server 1 registers the subscriber management information in the insurance subscriber DB 2 as indicated by the arrow A13 based on the user information including the above information.

FIG. 6 is a diagram showing an example of subscriber management information.

As shown in FIG. 6, the subscriber management information includes the user ID, password, name, my number, destination, and insurance ID provided as user information, as well as the insurance subscription number.

The insurance subscription number is the insurance subscription number issued to the user. The insurance subscription number issued to the user is specified based on the user ID and included in the subscriber management information. By registering the subscriber management information, My Number and the insurance subscription number will be linked in the insurance payment platform.

In the example of FIG. 6, insurance ID-1, insurance ID-2, and insurance ID-3 are shown as the insurance IDs of the insurances subscribed by the user. For example, each time the user subscribes to a new insurance, an additional insurance ID is registered.

In this way, in the insurance payment platform, not only are my numbers and insurance subscription numbers linked, but various identification information such as my numbers and insurance subscription numbers are linked to user IDs. Not only one insurance subscription number but also multiple insurance subscription numbers may be associated with one user ID.

The PF management server 1 manages contact information (notification destination) of each insurance company and insurance ID information sold by each insurance company. By linking the user ID with the insurance ID, the user ID is also linked with the destination of the notification to the insurance company.

When the subscriber management information is registered, as indicated by arrow A14 in FIG. 5, the PF management server 1 requests the eligibility confirmation agency to link and register the My Number and the insurance subscription number. The request to the eligibility confirmation agency is made by transmitting to the eligibility confirmation agency's system information requesting that a user with a specific My Number be associated with a specific insurance enrollment number and registered.

The system of the qualification confirmation agency confirms my number in response to a request from the PF management server 1, and stores the insurance subscription number in the server managed by the qualification confirmation agency. In the server managed by the qualification confirmation agency, the insurance subscription number is stored in association with the individual number.

Through the preparation process as described above, the insurance subscription number is linked to the My Number in each of the insurance payment platform and the eligibility confirmation agency.

Various identification information can be used as the insurer subscription number as long as it is an ID that can identify the user. Identification information linked to the insurer subscription number may be generated, and the generated identification information may be stored in the server of the eligibility verification agency in place of the insurer subscription number.

The My Number itself may be used in place of the insurance subscription number.

<Overall processing flow>
Here, the flow of processing of each device until the user receives the insurance money receipt recommendation will be described.

The overall processing until the user receives a recommendation to receive insurance benefits mainly consists of the processing from the user visiting a medical institution to confirming the health insurance qualification information, and the process from confirming the qualification information to receiving the insurance payment recommendation. is divided into the processing up to the transmission of

FIG. 7 is a diagram showing the flow of processing from when the user visits a medical institution to when he or she confirms health insurance qualification information. A medical institution is, for example, a medical institution or a pharmacy where medical care is possible.

When a user visits a medical institution as a patient due to illness or the like, the user causes the card reader 11 to read his or her My Number card as indicated by an arrow A21. A card reader 11 for reading the information stored in the IC chip of the My Number card is installed at the window of the medical institution.

When presenting the My Number card, consent to provide the receipt to the insurance payment platform will be confirmed. Consent confirmation is performed using, for example, a consent confirmation screen displayed on a display provided in the card reader 11 .

FIG. 8 is a diagram showing an example of a consent confirmation screen.

As shown in FIG. 8, the consent confirmation screen displays a message asking the user whether or not he or she agrees to provide the receipt to the insurance payment platform. Below the message, a button to press when agreeing and a button to press when not agreeing are displayed. A display of the card reader 11 is provided with, for example, a touch panel.

The user sees such a consent confirmation screen and selects whether or not to consent to providing the receipt to the insurance payment platform. If the user agrees to provide the receipt, consent information indicating this is generated and stored in the card reader 11 . Consent information is timestamped.

Consent information may be generated when consent is obtained using a reception device at the time of reception at a medical institution. For example, a device other than the card reader 11, such as a tablet terminal, is used as the reception device.

If consent is obtained from the patient or the patient's family, the information may be entered into the PC of the medical institution, and the consent information may be generated in the PC of the medical institution. In this case, confirmation of the patient's or patient's family's consent is done using a paper consent form.

Reception at a medical institution may be performed using a reception device or paper instead of using the My Number card. In this case, the card reader 11 is a device for confirming the validity of the electronic certificate stored in the My Number card.

The card reader 11 that has read the electronic certificate from the My Number card sends the electronic certificate to the online qualification confirmation system 13 managed by the qualification confirmation agency (online qualification confirmation system of the Payment Fund/National Health Insurance Central Association) as indicated by arrow A22. Submit and ask for credentials. If the user has agreed to provide the receipt to the insurance payment platform, the entitlement information with the insurance enrollment number is requested from the online entitlement verification system 13 .

Online eligibility confirmation uses a system that centrally manages the eligibility information of all citizens, and based on the patient's My Number card, the details of the medical insurance that the patient is enrolled in can be confirmed online. .

The online qualification confirmation system 13 inquires about the validity of the electronic certificate to a public personal authentication service (not shown) managed by the Local Government Information System Organization. If the electronic certificate is invalid, the online qualification confirmation system sends information indicating that the electronic certificate is invalid and the qualification information cannot be obtained to the business terminal 12 of the medical institution.

On the other hand, if the electronic certificate is valid, as indicated by an arrow A23, the online qualification confirmation system 13 transfers the qualification information tied to the electronic certificate (the qualification information tied to My Number tied to the electronic certificate) to an intermediate Read from server 14 . The intermediate server 14 is a server that links and manages My Numbers of all citizens and various types of information including qualification information.

The online qualification confirmation system 13 adds the insurance subscription number to the qualification information read from the intermediate server 14, and transmits the information to the business terminal 12 of the medical institution as indicated by arrow A24.

FIG. 9 is a diagram showing an example of credential information provided to medical institutions.

As shown in FIG. 9, the qualification information includes name, gender, date of birth, insurer name, insured person code number (health insurance), profit/loss information, and insurance subscription number.

The insurance subscription number added to the qualification information is the insurance subscription number that has been managed in association with the My Number by the qualification confirmation agency through advance preparation processing (Fig. 5).

The insurance subscription number may be obtained when the medical institution makes an inquiry instead of when the qualification information is obtained. For example, when the insurance subscription number is linked to My Number and managed in a minor portal, an inquiry is made from the business terminal 12 of the medical institution to the minor portal (a system that manages the minor portal), and the inquiry is answered An insurance enrollment number is obtained accordingly.

As shown in FIG. 7, the business terminal 12 that has acquired the insurance subscription number to which the qualification information is attached stores the qualification information and the patient ID in association with each other. A patient ID is patient identification information issued by a medical institution.

The above processing is performed when the user causes the card reader 11 to read the My Number card at the counter of the medical institution. After completing the reception including the presentation of the My Number card, the user will undergo a medical examination. Treatment, medication, drug delivery, hospitalization, etc., may be provided in lieu of or in conjunction with an examination by a doctor.

FIG. 10 is a diagram showing the flow of processing from confirmation of qualification information to transmission of an insurance payment receipt recommendation.

When the user, who is a patient, is finished with a medical examination, as shown in the left end of FIG. do.

When the medical institution where the reception using the My Number Card is performed is an insurance pharmacy, a dispensing fee statement is created as a receipt. In addition, when home-visit nursing is performed using the My Number card, a home-visit nursing medical expense statement is created as a receipt. The content of the user's treatment recorded in the receipt includes at least one of medical care content, dispensing content, and nursing care content.

If the user agrees to provide the insurance claim to the insurance payment platform, the business terminal 12 of the medical institution transmits the claim to the PF management server 1 as indicated by an arrow A31.

For example, if the consent information contains information indicating that you have consented to the receipt, or if the qualification information sent from the qualification confirmation agency contains the insurance enrollment number, It is determined that the user has agreed to provide the receipt to the insurance payment platform.

As shown in the balloon in FIG. 10, the receipt transmitted by the business terminal 12 includes the insurance enrollment number provided by the qualification verification agency.

As indicated by a two-way arrow A32, the PF management server 1 refers to the subscriber management information stored in the insurance subscriber DB 2, and based on the insurance subscriber number, determines the type of insurance the user is enrolled in. Identify. Here, the subscriber management information containing the same insurance subscription number as the insurance subscription number contained in the receipt is read from the insurance subscriber DB 2, and based on the insurance ID contained in the subscriber management information, the user is enrolled. The type of insurance is specified.

The PF management server 1 estimates the name of the user's disease based on the contents of the receipt. Scores are written on the receipt, and the name of the disease is not recorded. A disease name may be estimated using an inference model generated by machine learning. The inference model is generated by machine learning using combinations of medical insurance claims and disease names as learning data.

The PF management server 1 compares the estimated disease name with the insurance claim payment criteria to determine whether the insurance claim is payable. Determining whether insurance claims can be paid is a determination as to whether or not there is a possibility of paying insurance claims.

When determining that there is a possibility of payment of the insurance money, the PF management server 1 transmits an insurance money receipt recommendation to the user who is the insured person, as indicated by an arrow A33. The insurance payment receipt recommendation is sent by e-mail, for example. The destination of the e-mail is specified based on the information (FIG. 6) managed in the subscriber management information in association with the insurance subscription number.

Note that a plurality of destinations may be managed in association with insurance subscription numbers. This makes it possible to notify the insured's relatives and the like of the possibility of payment of insurance claims.

FIG. 11 is a diagram showing an example of an insurance payment receipt recommendation using e-mail.

As shown in FIG. 11, the body of the e-mail contains a message notifying that there is a possibility that the insurance money can be received. The message includes the URL to be accessed when confirming the intention to receive the insurance money.

When a user viewing such an e-mail using a device such as a smart phone selects a URL, a web browser is activated and the URL is accessed. A Web browser displays a confirmation screen. The display of the insurance payment receipt recommendation and the display of the intention confirmation screen may be performed by a dedicated application.

FIG. 12 is a diagram showing an example of an intention confirmation screen.

As shown in FIG. 12, the intention confirmation screen displays a message inquiring whether or not to confirm with the insurance company whether or not the insurance payment for the medical treatment received at the medical institution can be received.

Also, a message is displayed to confirm whether or not to agree to share the receipt with the insurance company. Information is also provided on how sharing receipts will facilitate smoother communication with insurance companies.

If confirmation with the insurance company is selected, the PF management server 1 notifies the insurance company of the possibility of insurance payment by transmitting user information to the insurance company.

In addition, when confirmation is made with the insurance company and sharing of the receipt is selected, the PF management server 1 transmits the receipt as indicated by arrow A34 in FIG. to the insurance company.

The insurance company that received the notification from the PF management server 1 contacts the insured person and confirms the documents necessary for receiving the insurance money. Communication between the insurer and the insured may be done using contact features provided by the insurance payment platform.

In this way, by using the insurance payment platform, the insured can be notified of the possibility of payment of insurance benefits simply by visiting a medical institution. The insured person does not have to compare his illness with the payment standards of each insurer, even if he has multiple policies.

On the other hand, the insurance company can easily confirm that the payment status of the insurance money has occurred.

Depending on the insurance company, the documents required to receive the insurance money may differ. By having the insurance payment platform determine whether or not the insurance payment can be paid as primary confirmation, and the insurance company's communication with the insured as secondary confirmation, insurance payment processing can be performed without significantly changing the insurance company's workflow. can be realized.

It is also conceivable that the determination of whether or not insurance claims can be paid using the insured person's insurance enrollment number and receipt will be made within the reception system of the medical institution. , which is not realistic.

In addition, it is difficult to determine whether or not an insurance claim can be paid within the reception system of a medical institution because criteria for disease determination differ among insurance companies. Since one user may subscribe to a plurality of insurance policies, it takes a long time to determine whether or not insurance claims can be paid for all insurance policies.

By allowing the insurance payment platform to determine whether insurance claims can be paid, it is possible to easily determine whether insurance claims can be paid without placing such a burden on the medical institution. It becomes possible.

<Configuration and Operation of PF Management Server 1>
Configuration of PF Management Server 1 FIG. 13 is a block diagram showing a configuration example of the PF management server 1. As shown in FIG.

As shown in FIG. 13, the PF management server 1 is composed of a computer. The PF management server 1 may be configured with a plurality of computers. When the PF management server 1 is composed of a plurality of computers, the various types of processing described above are realized through the cooperation of the respective computers.

A CPU (Central Processing Unit) 101 , a ROM (Read Only Memory) 102 and a RAM (Random Access Memory) 103 are interconnected by a bus 104 .

An input/output interface 105 is further connected to the bus 104 . Input unit 106 , output unit 107 , storage unit 108 , communication unit 109 , and drive 110 are connected to input/output interface 105 .

The input unit 106 is composed of a keyboard, a mouse, and the like. The output unit 107 is configured by a display or the like.

Storage unit 108 is configured by a hard disk, a non-volatile memory, or the like. The storage unit 108 stores various information such as programs executed by the CPU 101 .

A communication unit 109 is an interface to the Internet. For example, the communication unit 109 communicates with the business terminal 12 of the medical institution and receives a receipt transmitted from the business terminal 12 . In addition, the communication unit 109 communicates with a business terminal of an insurance company, and transmits to the insurance company a receipt of a user who has a possibility of paying an insurance claim.

The drive 110 controls writing of data to the removable medium 111 and reading of data from the removable medium 111 .

FIG. 14 is a block diagram showing a functional configuration example of the PF management server 1. As shown in FIG. At least some of the functional units shown in FIG. 14 are realized by executing a predetermined program by the CPU 101 shown in FIG.

As shown in FIG. 14, the PF management server 1 implements an information processing unit 121 . The information processing unit 121 includes an acquisition unit 131 , a readout unit 132 , a payment possibility determination unit 133 , a recommendation unit 134 and a transmission control unit 135 .

Acquisition unit 131 controls communication unit 109 to receive and acquire user information transmitted from the insurance company during preparation. The user information acquired by the acquisition unit 131 is supplied to the insurance subscriber DB 2 and stored as subscriber management information together with the insurance subscription number.

The acquisition unit 131 also communicates with the business terminal 12 of the medical institution. The acquisition unit 131 receives and acquires the receipt transmitted from the business terminal 12 . The receipt acquired by the acquisition unit 131 is supplied to the payment possibility determination unit 133 and the transmission control unit 135 .

The user information acquired by the acquisition unit 131 includes identification information including a user ID that is associated with the My Number. The acquisition unit 131 functions as an acquisition unit that acquires the identification information linked to the insured person's My Number and the insured person's receipt.

The reading unit 132 reads the subscriber management information of the user from the insurance subscriber DB 2 based on the insurance subscriber number included in the receipt. The subscriber management information read by the reading unit 132 is supplied to the payment possibility determination unit 133 , the recommendation unit 134 and the transmission control unit 135 .

In addition, the reading unit 132 reads out information regarding the insurance claim payment criteria for the insurance that the user subscribes to from the insurance subscriber DB 2 based on the insurance ID included in the subscriber management information. The information on the insurance claim payment criteria read by the reading unit 132 is supplied to the payment possibility determination unit 133 .

The read-out unit 132 functions as a read-out unit that reads out information regarding insurance claim payment criteria based on the insurance subscription number linked to the identification information in the subscriber management information.

The insurance subscriber DB 2 also stores information on the payment criteria for each insurance claim. The insurance subscriber DB 2 may be constructed in the storage unit 108, or may be constructed as an external database.

The payment determination unit 133 compares the receipt supplied from the acquisition unit 131 with the insurance payment criteria supplied from the reading unit 132 to determine whether the insurance payment can be made. Determining whether insurance claims can be paid is performed, for example, by estimating the user's disease name and symptoms based on the receipt and comparing the estimated disease name and the like with the insurance payment criteria. Information indicating the result of the insurance payable determination is supplied to the recommendation unit 134 and the transmission control unit 135 .

When it is determined that there is a possibility of insurance payment, the recommendation unit 134 transmits an insurance payment receipt recommendation to the user. An insurance payment receipt recommendation is transmitted from the communication unit 109 under the control of the recommendation unit 134 . The destination included in the subscriber management information is used as the destination of the insurance payment receipt recommendation.

In addition, when the recommendation unit 134 determines that there is no possibility of payment of the insurance claim, the recommendation unit 134 transmits a notification indicating that fact to the user.

When it is determined that there is a possibility of payment of the insurance claim, the transmission control section 135 controls the communication section 109 and transmits information indicating that fact to the insurance company.

Further, when the user agrees to provide the receipt, the transmission control unit 135 transmits the receipt supplied from the acquisition unit 131 to the insurance company. The transmission control unit 135 functions as a transmission unit that transmits a receipt to the insurance company based on the user's consent as a response to the insurance payment receipt recommendation.

·Operation of PF Management Server 1 Here, the processing of the PF management server 1 having the configuration as described above will be described with reference to the flowchart of FIG.

In step S1, the acquiring unit 131 acquires a receipt transmitted from the business terminal 12 of the medical institution.

In step S2, the reading unit 132 reads the subscriber management information of the user from the insurance subscriber DB 2 based on the insurance subscriber number included in the receipt. Further, the reading unit 132 reads information on the payment criteria of the insurance that the user subscribes to from the insurance subscriber DB 2 based on the insurance ID included in the subscriber management information.

In step S3, the payment propriety determination unit 133 compares the disease name estimated based on the receipt with the insurance payment criteria to determine whether or not the insurance money can be paid.

In step S4, the payment availability determination unit 133 determines whether or not there is a possibility of payment of the insurance claim.

If it is determined in step S4 that there is a possibility of insurance payment, in step S5, the recommendation unit 134 sends an insurance payment receipt recommendation, which is a notification of the possibility of insurance payment, to the registered user. Send to destination.

In step S6, the transmission control unit 135 transmits to the insurance company a notification to the effect that there is a possibility of payment of the insurance claim together with the receipt. The receipt is sent when the user agrees.

After that, the processing of the PF management server 1 ends. Similarly, when it is determined in step S4 that there is no possibility of payment of the insurance claim, the user is appropriately notified that there is no possibility of payment of the insurance claim, and then the process ends.

<Modification>
Although the determination of the payability of medical insurance and life insurance claims is made, it is also possible that the determination of the payability of other types of voluntary insurance is made in the insurance payment platform. good.

For example, determinations about the payability of fire insurance and earthquake insurance claims can be made in the insurance payment platform. In this case, the same processing as the above-described processing performed at medical institutions is performed at police stations, government offices of local public bodies, and the like.

Only information from registered institutions, such as certain medical institutions, may be accepted at the insurance payment platform. In this case, an institution identification code is assigned to each institution. By performing authentication using the institution identification code on the insurance payment platform before sending/receiving the receipt including the insurance enrollment number, it is possible to reduce the risk of the insurer enrollment number and receipt being leaked to the outside.

・Example using a blockchain database The determination result regarding the possibility of insurance payment may be stored in association with information such as the insurance subscription number and insurance ID.

Fraud can occur during insurance payment transactions, so it is necessary to keep an accurate history of transactions. In addition, the insurance company also needs to confirm whether all payment obligations have been met.

A blockchain database is used as a storage destination for determination result information regarding the determination result regarding the possibility of paying an insurance claim. The blockchain database also stores information about whether insurance claims have been paid.

FIG. 16 is a diagram illustrating an example of a blockchain database that serves as a storage destination of determination result information.

As shown in FIG. 16, a consortium-type blockchain network 201 is used as a blockchain database. The blockchain network 201 is a P2P network composed of multiple nodes managed by multiple participants. A node is a device such as a server. One node may be composed of one device, or may be composed of a plurality of devices.

Various information can be stored in the blockchain network 201 from the PF management server 1 and the server 202, which is the server of the insurance company. For example, a server 202 is prepared for each insurance company.

As described above, when the PF management server 1 determines that there is a possibility of payment of an insurance claim, it causes the block chain network 201 to store determination result information including the insurance subscription number and the insurance ID. Since it is highly protected personal information, it is preferable not to store the receipt provided by the medical institution in the blockchain network 201 .

When the insurance company receives notification from the PF management server 1 that there is a possibility of payment, the insurance company also determines whether there is a possibility of payment and notifies the insurance payment platform of the determination result. . When the insurance payment platform is notified of the determination result of whether or not there is a possibility of payment of insurance claims, the server 202 confirms that the payment of insurance claims has been completed for the insurance that has been determined to have the possibility of payment of insurance claims. Information indicating whether or not is stored in the blockchain network 201 .

FIG. 17 is a diagram showing an example of transaction data stored in the blockchain network 201 by the PF management server 1. As shown in FIG.

As shown in FIG. 17, the transaction data generated by the PF management server 1 includes the electronic signature of the insurance payment platform, the public key of the insurance payment platform, the address of the insurance payment platform, the destination address, the insurance subscription number, the insurance ID, and information indicating whether or not the insurance company has been notified of the possibility of payment of insurance claims.

The destination address represents the destination used by the insurance payment platform as the destination of the insurance receipt recommendation. The insurance enrollment number is preferably encrypted by hashing or the like.

For example, when transaction data including each piece of information in FIG. 17 is stored in the blockchain network 201, information indicating that is transmitted to the insurance company by the transmission control unit 135, for example. The information sent to the insurance company includes the policy number.

FIG. 18 is a diagram showing an example of transaction data stored in blockchain network 201 by server 202 .

As shown in FIG. 18, the transaction data generated by the server 202 includes the electronic signature of the insurance company, the public key of the insurance company, the address of the insurance company, the destination address, the insurance subscription number, the insurance ID, and the amount of insurance money. Information is included that indicates whether payment has been completed.

The destination address represents the payee of the insurance money. The insurance enrollment number is preferably encrypted by hashing or the like.

Transactions for writing such transaction data are stored in blocks that make up the blockchain network 201 . Blocks store the hash value of the previous block along with multiple transactions.

The user's personal information can be protected by preventing the medical information from being included in any of the transaction data generated by the PF management server 1 and the transaction data generated by the server 202 .

- Example of information managed in the insurance payment platform Information indicating whether or not the insurance payment has been completed may be transmitted from the insurance company to the insurance payment platform and accumulated in the insurance payment platform. The insurance payment platform manages the information sent from the insurance company so that the user can confirm at any time whether or not the insurance payment has been made.

For example, by accessing the insurance payment platform, users can view information such as which insurance they are in, when the insurance benefit is paid for which insurance, and how much the monthly insurance premium is. may Also, these pieces of information may be linked to My Number and posted on the Mynaportal with the user's consent.

・Example of determination in insurance payment platform , and the determination of the content of payment may be performed by the payment determination unit 133 . As for the insurance that compensates for the transfer of anything other than money, the content of the compensation may be determined by the payment determination unit 133 .

If it is determined that there is a possibility of payment of the insurance claim, the recommendation unit 134 notifies that the insurance claim is likely to be paid, and sends information representing the content of the payment to at least one of the user and the insurance company. will be sent.

Determinations other than whether a claim is payable may be made at the insurance payment platform.

For example, a determination may be made at the insurance payment platform whether a user who is an insurance policyholder has fulfilled their insurance disclosure obligations. Determination of whether or not the insurance disclosure obligation is fulfilled is based on, for example, at least one of past medical examination results obtained from Mynaportal and medical information representing the content of medical treatment received by the user in the past. is done.

Determination of whether or not the user has fulfilled the obligation to disclose insurance is made at a predetermined timing, such as when the user applies for insurance to the insurance company, or when it is determined whether or not the insurance claim can be paid. The determination of whether or not the insurance disclosure obligation is fulfilled may be made based on the consent of the user and the application of the insurance company.

Various determinations including the determination of whether insurance claims can be paid may be made using an inference model generated by machine learning.

FIG. 19 is a diagram showing an example of an inference model provided in the payment availability determination unit 133. As shown in FIG.

As shown in FIG. 19, the payment availability determination unit 133 is provided with a payment availability determination model 133A that is used to determine whether insurance claims can be paid. The payment propriety determination model 133A is an inference model composed of a neural network or the like generated by machine learning based on a genetic algorithm. For example, the payability determination model 133A is generated by performing machine learning based on a learning data group that links the receipt, the type of insurance, and the determination result of the possibility of payment of the insurance claim. Note that the receipt may be other medical information indicating the details of medical care.

A receipt and the type of insurance are input to the payment possibility determination model 133A, and the result of determination as to whether or not there is a possibility of payment of the insurance claim is output. By using the payment possibility determination model 133A, it is possible to determine whether or not there is a possibility of payment of the insurance claim based on the receipt and the type of insurance.

Based on a plurality of receipts transmitted from the same medical institution, the validity of the receipt may be analyzed by the payment determination unit 133 . In this case, statistical analysis is performed on a plurality of claims, and whether or not the claims are valid is output as an analysis result.

For example, if it is determined that there are statistically more similar receipts sent from a specific medical institution than those sent from other medical institutions, there is a possibility of fraud. and an alert is output to the administrator of the insurance payment platform.

In this way, it is possible to give the payment propriety determination unit 133 the function of an analysis unit that statistically analyzes a plurality of receipts transmitted from the same medical institution.

The validity of diagnosis and treatment at each medical institution may be statistically determined based on a plurality of receipts. For example, validity is determined based on whether or not there is a possibility that the medical institution is providing too much or too little diagnosis or treatment compared to other medical institutions. As a result, insurance companies can investigate medical institutions that provide more appropriate diagnosis and treatment, and recommend appropriate medical institutions to policyholders.

・If you receive medical treatment without submitting your health insurance card or if you receive medical treatment without submitting your health insurance card, or if you receive medical treatment without submitting your health insurance card, medical information entered by the medical institution A linked invitation may be issued and sent to the user. An invitation is a format for submitting medical information to an insurance payment platform, such as an email or an online response form. For example, when the user receives free medical care at a medical institution, the medical institution accesses the insurance payment platform and inputs the contents of the free medical care according to a predetermined format. The insurance payment platform generates medical information and an online response form based on the entered medical details, and links medical information and invitations to the temporarily generated ID. The medical institution sends the user the URL of the online response form or a code (eg, QR code) for accessing the online response form. The user accesses the online response form and enters and submits the Individual Number. Note that user authentication may be performed by entering a user ID and password instead of entering the My Number. The insurance payment platform associates and stores medical information with the entered My Number or user ID, and executes the above-mentioned insurance payment possibility determination and recommendation processing. As a result, the user can easily know that there is a possibility of payment of the insurance benefit even if the user receives medical treatment without presenting the health insurance card or in the case of free medical treatment.

- Program The series of processes described above can be executed by hardware or by software. When a series of processes is executed by software, a program that constitutes the software is installed in a computer built into dedicated hardware or a general-purpose personal computer.

The program to be installed is provided by being recorded on removable media 111 shown in FIG. Alternatively, it may be provided via a wired or wireless transmission medium such as a local area network, the Internet, or digital broadcasting. The program can be pre-installed in the ROM 102 or storage unit 108 .

The program executed by the computer may be a program in which processing is performed in chronological order according to the order described in this specification, or a program in which processing is performed in parallel or at necessary timing such as when a call is made. It may be a program that is carried out.

In this specification, a system means a set of multiple components (devices, modules (parts), etc.), whether or not all components are in the same housing. Therefore, a plurality of devices housed in separate housings and connected via a network, and a single device housing a plurality of modules in one housing, are both systems. .

Note that the effects described in this specification are merely examples and are not limited, and other effects may be provided.

Embodiments of the present technology are not limited to the above-described embodiments, and various modifications are possible without departing from the gist of the present technology.

For example, the present technology can take a configuration of cloud computing in which one function is shared by a plurality of devices via a network and processed jointly.

Further, each step described in the flowchart above can be executed by one device, or can be shared by a plurality of devices and executed.

Furthermore, when one step includes a plurality of processes, the plurality of processes included in the one step can be executed by one device or shared by a plurality of devices.

- Configuration example combination The present technology can also take the following configurations.

(1)
an acquisition unit that acquires identification information linked to the insured person's My Number and medical information representing the details of the treatment received by the insured person;
a reading unit that reads out information regarding payment standards of insurance that the insured person subscribes to, based on one or more insurance subscription numbers linked to the identification information;
a determination unit that determines whether or not there is a possibility of payment of an insurance claim based on the medical information and the payment criteria;
and a recommendation unit that, when it is determined that there is a possibility of payment of an insurance claim, sends a notification that there is a possibility of payment of an insurance claim to a first destination linked to the identification information. insurance payment system.
(2)
The content of treatment represented by the medical care information includes at least one of the content of medical care, the content of dispensing, and the content of nursing that are covered by health insurance The insurance payment system according to (1) above .
(3)
(1) or (2) above, wherein, when it is determined that there is no possibility of payment of the insurance claim, the recommendation unit transmits a notification of the impossibility of payment of the insurance claim to the first destination. insurance payment system.
(4)
The (1 ) to (3), the insurance payment system.
(5)
When data including the result of determination as to whether or not there is a possibility of payment of an insurance claim and the insurance enrollment number are stored in a blockchain database, the transmitting unit transmits the information including the insurance enrollment number to the second The insurance payment system according to (4) above, which transmits to a destination.
(6)
The determination unit further determines the content of the payment related to the insurance determined to be likely to be paid,
The insurance payment system according to any one of (1) to (5), wherein the recommendation unit transmits a notification of payment details to the insured person or the insurance company.
(7)
The determination unit determines the obligation to disclose insurance based on at least one of the results of past medical examinations of the insured person and other medical information representing the content of medical treatment received by the insured person in the past. The insurance payment system according to any one of (1) to (6) above, wherein it is determined whether or not the insured person is fulfilled.
(8)
The insurance payment system according to any one of (1) to (7), wherein the determination unit uses an inference model generated by machine learning to determine whether there is a possibility of payment of an insurance claim.
(9)
The insurance payment according to any one of the above (1) to (8), further comprising an analysis unit that performs statistical analysis based on a plurality of pieces of medical information issued by the same medical institution and outputs analysis results of the validity of the contents. system.
(10)
The information processing device that manages the insurance payment system
Acquiring identification information linked to the insured person's My Number and medical information representing the details of the treatment received by the insured person,
Based on one or more insurance subscription numbers linked to the identification information, read out information regarding payment criteria for insurance that the insured person subscribes to,
Determining whether there is a possibility of insurance payment based on the medical information and the payment criteria,
An information processing method, wherein, when it is determined that there is a possibility of payment of an insurance claim, a notification of the possibility of payment of an insurance claim is transmitted to a destination associated with the identification information.
(11)
to the computer,
Acquiring identification information linked to the insured person's My Number and medical information representing the details of the treatment received by the insured person,
Based on one or more insurance subscription numbers linked to the identification information, read out information regarding payment criteria for insurance that the insured person subscribes to,
Determining whether there is a possibility of insurance payment based on the medical information and the payment criteria,
A program for executing a process of sending a notice of the possibility of payment of an insurance claim to a destination associated with the identification information when it is determined that there is a possibility of payment of the insurance claim.

1 PF Management Server, 2 Insurance Subscriber DB, 11 Card Reader, 12 Business Terminal, 13 Online Qualification Confirmation System, 14 Intermediate Server, 121 Information Processing Unit, 131 Acquisition Unit, 132 Reading Unit, 133 Payment Acceptability Determining Unit, 134 recommendation unit, 135 transmission control unit

Claims (11)

an acquisition unit that acquires identification information linked to the insured person's My Number and medical information representing the details of the treatment received by the insured person;
a reading unit that reads out information regarding payment standards of insurance that the insured person subscribes to, based on one or more insurance subscription numbers linked to the identification information;
a determination unit that determines whether or not there is a possibility of payment of an insurance claim based on the medical information and the payment criteria;
and a recommendation unit that, when it is determined that there is a possibility of payment of an insurance claim, sends a notification that there is a possibility of payment of an insurance claim to a first destination linked to the identification information. insurance payment system. 2. The insurance payment system according to claim 1, wherein the details of treatment indicated by said medical care information include at least one of details of medical care covered by health insurance, details of dispensing, and details of nursing. The insurance payment system according to Claim 1, wherein, when it is determined that there is no possibility of paying an insurance claim, the recommendation unit transmits to the first destination a notification that there is no possibility of paying an insurance claim. Claim 1, further comprising a transmitting unit configured to transmit the medical information to a second destination associated with the identification information based on a response from the insured person to the notification of the possibility of insurance payment. The insurance payment system described in . When data including the result of determination as to whether or not there is a possibility of payment of an insurance claim and the insurance enrollment number are stored in a blockchain database, the transmitting unit transmits the information including the insurance enrollment number to the second 5. The insurance payment system of claim 4, transmitting to a destination. The determination unit further determines the content of the payment related to the insurance determined to be likely to be paid,
The insurance payment system according to claim 1, wherein the recommendation unit transmits a notification of payment details to the insured person or the insurance company. The determination unit determines the obligation to disclose insurance based on at least one of the results of past medical examinations of the insured person and other medical information representing the content of medical treatment received by the insured person in the past. 2. The insurance payment system of claim 1, wherein determining whether the insured is fulfilling. The insurance payment system according to Claim 1, wherein the determination unit determines whether or not there is a possibility of payment of an insurance claim using an inference model generated by machine learning. 2. The insurance payment system according to claim 1, further comprising an analysis unit that performs statistical analysis based on a plurality of pieces of medical information issued by the same medical institution and outputs an analysis result of validity of the content. The information processing device that manages the insurance payment system
Acquiring identification information linked to the insured person's My Number and medical information representing the details of the treatment received by the insured person,
Based on one or more insurance subscription numbers linked to the identification information, read out information regarding payment criteria for insurance that the insured person subscribes to,
Determining whether there is a possibility of insurance payment based on the medical information and the payment criteria,
An information processing method, wherein, when it is determined that there is a possibility of payment of an insurance claim, a notification of the possibility of payment of an insurance claim is transmitted to a destination associated with the identification information. to the computer,
Acquiring identification information linked to the insured person's My Number and medical information representing the details of the treatment received by the insured person,
Based on one or more insurance subscription numbers linked to the identification information, read out information regarding payment criteria for insurance that the insured person subscribes to,
Determining whether there is a possibility of insurance payment based on the medical information and the payment criteria,
A program for executing a process of sending a notice of the possibility of payment of an insurance claim to a destination associated with the identification information when it is determined that there is a possibility of payment of the insurance claim.

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