JPWO2018179375A1 - Insurance reimbursement processing or insurance factoring processing system - Google Patents

Abstract

It intervenes between patients, osteopaths, insurers, and financial institutions, and replaces or factors in some or all of the receipt brokerage and insurance claims. An insurance payment amount input means 111 for receiving an input of an insurance payment amount based on receipt data relating to the insurance payment request from the insurance claimant terminal, and an input of a desired replacement or factoring amount for the insurance payment amount Replacement or factoring desired amount input means 122, replacement or factoring upper limit ratio setting means 123 for setting a replacement or factoring upper limit rate for each insurance claimant or for each transaction of replacement or factoring processing, and replacement or factoring desired amount for insurance payment It is configured to include an advance or factoring availability determination means 126 that permits advancement or factoring execution when the billing amount is equal to or less than the amount obtained by multiplying the amount of advancement or the factoring upper limit rate.

Description

  The present invention is a medical institution that can use medical insurance, a dental clinic, a pharmacy, an osteopathic clinic, an acupuncture clinic, an Anma massage clinic, a physical therapy clinic, an occupational therapy clinic, etc. The present invention relates to a system for claiming insurance payments used by occupational therapy clinics.

  The receipt data is data representing the contents of an insurance payment request form (receipt). Here, “receipt” refers to a payment request application for requesting payment of medical fees, care fees, and medical expenses. Currently, medical fees for medical institutions are submitted to the insurer after review at the Receipt Review Organization (National Health Insurance Association (National Health Insurance Federation), Social Insurance Medical Fee Payment Fund (Payment Fund)). In some cases, medical expenses may be submitted directly to the insurer.

Under the health insurance system and the national health insurance system, medical fees are determined for each medical practice such as diagnosis, surgical procedure, medication, and testing for the insured patient. In accordance with the rules for medical fees, the institution requests payment of medical expenses from the insurer (municipal municipal public health association, mutual aid association, health insurance association) to which the patient belongs using the created receipt.
Treatment costs are determined according to the treatment contents of the Osteopathic Hospital, Acupuncture Hospital, Anma Massage Hospital, etc., and the patient belongs to the treatment type period in which these treatments are performed using the created receipt according to the rules for claims for medical expenses. Ask the insurer to pay for the medical expenses.
Under the Long-Term Care Insurance System, long-term care fees are determined for each type of service such as long-term care and life support for users who are insured, and long-term care providers who provide services based on the created care plan In accordance with these rules, the insurer to whom the user belongs is requested to pay the nursing care fee.

In the following, insurance payment request processing will be explained, but even if it is a hospitalized type (a type in which a user who is insured goes to a service provider such as a medical institution that is an insurance user), a visit type (insurance use) Even if the service provider such as the medical institution who is the person goes to the home of the user who is the insured person), the flow of the subsequent insurance claim processing except for the flow of service provision and the difference in location Are basically the same. Further, even if there is a difference in the contents of claims such as medical treatment fee, application for payment of medical expenses, and nursing care fee, the flow of subsequent insurance payment request processing is basically the same.
Hereinafter, as an example, a flow of insurance payment request processing for a general visit type judo reduction medical treatment application will be described.

  FIG. 14 is a diagram showing an outline of a request for payment, examination and payment of a medical expenses application for a visit type judo reduction in a conventional general osteotomy. As shown in FIG. 14, it is explained as a three-party model of patient A, osteopath B, and insurer D.

  Patient A presents his / her insurance card at Osteopath B. At Osteopath B, a judo reducer writes an interview sheet and the like through an interview with patient A, and then makes a treatment plan. Here, in the case of acute and subacute bruise treatment and sprain treatment, a medical treatment payment application form is required when applying for medical treatment. Although the patient's signature is originally required for the application for payment of medical treatment expenses, the timing of the receipt creation process and the receipt delivery process for the payment request does not match the timing of the patient visit, and the patient signature is required at the time of receipt creation and delivery. It is virtually difficult to get Therefore, the current situation is that a signature is given to the patient at the first examination and a blank sheet is attached.

  Osteopath B prepares a receipt for the treatment and sends the receipt directly to the insurer D (municipal health insurance association, mutual aid association, health insurance association). The insurer D examines the legitimacy of the receipt, and if it is valid, pays the medical expenses to the osteopath B.

  As shown in FIG. 14, in the medical treatment payment flow in the prior art, the medical treatment payment is made by the receipt preparation work processing based on the surgical operation in the osteopath B, the receipt sending paper treatment, and the receipt at the insurer D. It is performed through examination paperwork, payment paperwork from the insurer D to the osteopath B.

  However, in the conventional three-party model of the patient A, the osteopath B, and the insurer D, since the osteoclast B performed the billing work on its own to create a receipt, an improper insurance claim was a problem. Inappropriate insurance claims may be due to negligence or intentional fraud. If it is an error billing due to negligence, it is easy to prevent it by devising check methods such as checking the suitability of the treatment contents and the fee for the treatment, and checking the recalculation of the fee for the treatment. However, it is said that it is difficult to check for intentional fraud.

Here, a technique for proposing a model different from the conventional three-party model is known.
FIG. 15 is a diagram for explaining a system disclosed in Japanese Patent Laid-Open No. 2001-344337. It is explained as a four-party model of patient A, osteopath B, mediator C, and insurer D. This is a model in which patient A visits osteotomy B.
The technique disclosed in Japanese Patent Laid-Open No. 2001-344337 is a model in which an intermediary organization C is added between a treatment center B and an insurer D. The content of intermediary processing includes receipt / reception of payment information, transmission / reception of payment information, and a receipt returned. Sending and receiving information. The returned receipt is a receipt with which the insurer D has reserved payment and is returned to the treatment center B. The technique disclosed in Japanese Patent Laid-Open No. 2001-344337 prevents unauthorized charges, and particularly discloses that handling of a return receipt is automated. The payment information is simply relayed.

JP 2001-344337 A

The problem with the prior art is that there is a large time lag from the date of treatment at Osteopath B to the date of payment of actual medical expenses by the insurer D. This time lag is usually large and takes about 2 to 3 months.
Osteopathic B has a small business scale such as individual management, and the time lag from the date of treatment to the date of payment of actual medical expenses is often a big business problem.

  The time lag between the receipt of the receipt to the insurer D and the completion of payment of the medical expenses from the insurer D is an institutional problem, and this time lag must be borne by someone. Usually, Osteopath B itself bears this time lag. In Japanese Patent Laid-Open No. 2001-344337, the brokerage institution C performs a process for submitting a receipt to the insurer D and a settlement process related to the medical expenses.

Therefore, the system used by the brokerage institution C is not only a function for performing an appropriate process with knowledge and know-how regarding the receipt regarding the receipt creation process and the submission process to the insurer D, but also in the settlement process and the osteopath B It is preferable to have a resetting function that bears a time lag from the treatment date to the date of completion of payment of the actual medical expenses by the insurer D, and a factoring function that transfers medical fee receivables and nursing care receivables.
Here, the term “reimbursement” means that money transfer is temporarily reassigned without the transfer of medical treatment receivables or medical expenses receivables or nursing remuneration receivables in medical insurance. Factoring means that money is transferred by transferring receivables. The two are distinguished by whether or not the receivables are transferred, but the medical treatment fee in medical insurance and the long-term care fee in long-term care insurance are legally allowed to transfer the receivable, while the payment of medical expenses is legally permitted to transfer the receivable Absent. For this reason, medical institutions and nursing care establishments generally use factoring processing that involves the transfer of receivables, and for businesses that receive medical expenses payments such as osteopaths, use reimbursement processing that does not involve the transfer of receivables. Become.

In this way, it is convenient if factoring can be used from the insurance payment request until payment of the medical treatment fee or nursing care fee is completed, or reimbursement can be used until payment of the medical treatment fee is completed. On the other hand, there may be a case where the insurance payment request is returned for reasons such as incomplete receipt and insurance payment is not executed. Therefore, there is a certain risk in the reimbursement and factoring of insurance claims.
Further, there is a case where the reorganization or factoring by the intermediary agency C is not required depending on the situation of the insurer D. Initially, there was no need for the reorganization or factoring by the intermediary agency C, but the situation changes and the execution of restructuring or factoring is requested. In some cases.

  In view of the above problems, an object of the present invention is to provide a system that intervenes between an insured person, a service provider, and an insurer, and performs a replacement execution process or a factoring execution process in order to reduce a time lag of a settlement process. And

In order to achieve the above object, the insurance reimbursement processing or insurance factoring processing system according to the present invention relates to a medical insurance or long-term care insurance insurance claim processing by a person who makes a medical insurance claim or a long-term care insurance claimant. It intervenes between the insurance claimant terminal to be used, the insurer terminal used by the insurer, and the examination terminal used by the receipt examination body, and mediates insurance claim processing for claiming insurance to the insurer. In addition, an insurance reimbursement process or an insurance factoring processing system for performing reimbursement or factoring process for temporarily reimbursing part or all of the amount of the insurance payment claim and prepaying to the insurance claimant, the insurance claimant terminal The insurance that accepts the input of the insurance claim amount based on the receipt data for the insurance claim from A billing amount input means, a replacement or factoring desired amount input means for accepting input of a desired advance or factoring desired amount for the insurance claim amount from the insurance claimant terminal, and each insurance claimant or the A replacement or factoring upper limit rate setting means for setting a replacement or factoring upper limit rate for the insurance claim amount for each transaction of the replacement or factoring process, and the replacement or factoring desired amount is added to the insurance claim amount by the replacement or factoring upper limit. An insurance reimbursement process or an insurance factoring processing system comprising a replacement or factoring availability determination unit that permits replacement or factoring execution when the amount is equal to or less than the amount multiplied by the rate.
In addition, there is a replacement or factoring fee rate setting means for setting a replacement or factoring fee rate for each transaction of replacement or factoring processing, and presents the replacement or factoring ceiling rate and the replacement or factoring fee rate to the insurance claimant terminal. You can also
With the above configuration, it is possible to set a replacement or factoring ceiling rate and a replacement or factoring fee rate for the insurance claim amount for each insurance claimant or for each transaction of the replacement or factoring process. Can be woven flexibly.

  Receipt return in insurance claims is often influenced by the skill of the claimant who creates the receipt, so it is a system to set the advance or factoring ceiling rate or advance or factoring fee rate according to the claimant. It can be said that it is a preferable process in operation. In addition, the receipt return for insurance claims is affected by the complexity of the contents of medical treatments, treatments, and services performed by medical institutions, treatment facilities, and nursing care facilities, as well as the experience and accumulation of past receipt processing related to similar content. Therefore, setting the replacement or factoring upper limit rate or the replacement or factoring fee rate according to the transaction contents of the replacement or factoring process is a preferable process in terms of system operation.

Here, each insurance claimant is configured to have an insurance claimant database in which the return rate of past receipts and credit information are accumulated, and a replacement or factoring upper limit rate setting means is used for the replacement or factoring upper limit rate, In setting the factoring fee rate, it is preferable to calculate the factoring fee rate in consideration of the total amount of insurance claim processing to be processed, the return rate of the insurance claimant's past receipt, and the credit information of the claimant.
When calculating the reimbursement amount for a receipt to be processed, it is preferable to take into account the total amount of insurance claim processing covered, as well as the insurance claimant's historical receipt return rate and the insurance claimant's credit. This is because it is preferable to calculate in consideration of information.

  In addition, the insurance claimant terminal has an examination pass expectation rate input means for receiving the expected assessment pass rate of the receipt data determined by the application that created the receipt data at the insurance claimant terminal. It is preferable that the advance or factoring upper limit rate is adjusted accordingly, or the advance or factoring fee rate setting means adjusts the advance or factoring fee rate according to the expected examination pass rate.

  The ordinary receipt creation system only creates and outputs a receipt based on data input by the insurance claimant, but the receipt creation system planned to be provided by the applicant, LEIS, The receipt is created based on the data entered by the claimant, and the probability of the receipt being passed is calculated by calculating the “predicted passing rate”, which is the probability of passing the review at the receipt reviewing institution. It can be provided to a processing or insurance factoring processing system. By using this “expected pass rate”, there is a risk that the receipt will fail the receipt review and the insurance amount will not be collected, or the insurance amount will be delayed through a procedure such as correction after the return. Can be woven. It is possible to use the “examination pass prediction rate” for each transaction of such a receipt by linking the receipt creation system and the insurance reimbursement process or the insurance factoring process system.

  In addition, it includes a receipt creation application recognition means that automatically recognizes environmental conditions such as the type, version, and database of the application that created the receipt data at the insurance claimant terminal. It is preferable that the advance or factoring upper limit rate is adjusted according to the type of creation application, or the advance or factoring fee rate setting means adjusts the advance or factoring fee rate according to the type of the receipt creation application.

  Processing in the receipt creation application is not easy, and depending on the application, the accuracy (rejection or failure) of the receipt may differ, and the return rate may change. Therefore, the advance or factoring upper limit rate or the advance or factoring fee rate is adjusted according to the type of receipt creation application used by the insurance claimant. If information on the type of receipt creation application is used in this way, the receipt will fail the receipt review and the insurance amount will not be collected, or the return of the insurance amount will be delayed through procedures such as correction after returning. Risk can be factored in. Such processing is possible by recognizing the type of receipt creation application for each transaction of the receipt, and by linking the receipt creation system with the insurance reimbursement processing or insurance factoring processing system.

  The above replacement or factoring process does not necessarily force the use, and it is preferable that the insurance claimant can freely select. Therefore, the insurance reimbursement process or insurance factoring processing system of the present invention comprises a reimbursement or factoring selection means for allowing the insurance payer to input a selection as to whether or not reimbursement or factoring process is desired. It is also possible to adopt a mechanism in which the acceptance screen for the input of the change or factoring desired amount by the advance or factoring desired amount input means is presented only when the request for the change or factoring process is input via.

The insurance replacement process or insurance factoring processing system 100 of the present invention preferably includes a simulation function.
The insurance claim amount input means accepts provisional input of the insurance claim amount from the insurance claimant terminal, and the replacement or factoring desired amount input means accepts the provisional input of the replacement or factoring desired amount from the insurance claimant terminal. Based on the insurance claim amount entered and the desired replacement or factoring amount, the user can present the simulation result including the replacement or factoring result and the amount to be paid to the insurance claimant terminal. You can check in advance whether the result will be factoring.
Further, it is possible to devise a method that can be flexibly changed later on the replacement or factoring execution established in the past.
In the insurance reimbursement processing or insurance factoring processing system of the present invention, the reimbursement or factoring processing executed in the intermediation processing of the insurance claim processing performed in the past is within a predetermined period (for example, within the period during the receipt examination). It is also possible to permit past change or factoring desired amount to be changed via the change or factoring desired amount input means. If the advance or factoring desired amount is changed, the advance or factoring process is executed for the difference.
Similarly, in the insurance reimbursement processing or insurance factoring processing system of the present invention, in the mediation processing of the insurance payment request processing performed in the past, the desire for replacement or factoring processing was not selected via the replacement or factoring selection means. If it is within a predetermined period, it is also possible to allow the change of past change or factoring desired selection through the change or factoring selection means and execute the change or factoring process.

  The insurance reimbursement processing or insurance factoring processing system according to the present invention includes a receipt data input means for receiving receipt data related to the insurance payment request from the insurance payment requester terminal as an intermediary process of the insurance payment request processing, and the receipt data as the insurer. The insurance payment request processing means for transmitting the insurance payment request processing to the examination authority terminal used by the terminal or the inspection body designated by the insurer, and each insurance payment processing according to the determination of the replacement or factoring determination means For this, a replacement or factoring determination means for determining execution of the replacement or factoring process is provided.

It is a figure which shows simply the basic composition of the insurance replacement process or insurance factoring processing system 100 of this invention. It is the figure (the 1) which shows the flow of the receipt data mediation process and the change or factoring process using the insurance change process or insurance factoring process system 100 of this invention. It is the figure (the 2) which shows the flow of the mediation process of receipt data and the change or factoring process using the insurance change process or insurance factoring process system 100 of this invention. It is a figure which shows the example of a replacement or factoring selection screen It is the figure (the 3) which shows the flow of the mediation process of receipt data and the change or factoring process using the insurance change process or insurance factoring process system 100 of this invention. It is a figure which shows the example of a change or factoring desired amount input screen. It is a figure which shows various simulation results. It is the figure (the 4) which shows the flow of the mediation process of receipt data and the change or factoring process using the insurance change process or insurance factoring process system 100 of this invention. 5 is a flowchart (first half) of receipt data mediation processing and replacement or factoring processing by the insurance replacement processing or insurance factoring processing system 100 of the present invention. It is a flowchart (second half) of receipt data mediation processing and replacement or factoring processing by the insurance replacement processing or insurance factoring processing system 100 of the present invention. It is a figure which shows the example of the screen which sets again the selection of replacement | exchange or factoring utilization determined in the past within a predetermined period. It is a figure which shows the example of the screen which performs the change of the change or factoring process content determined in the past within a predetermined period. It is a figure which shows simply the basic composition of the insurance reimbursement processing or insurance factoring processing system 100a of this invention concerning Example 2. FIG. The figure which shows the outline of the medical treatment payment application and examination and payment of the visit type judo reduction in the conventional general osteopathic clinic The figure explaining the prior art disclosed by Unexamined-Japanese-Patent No. 2001-344337

  Hereinafter, the best mode for carrying out the present invention will be described specifically by way of examples. The present invention is not limited to these examples.

A configuration example of an insurance replacement process or an insurance factoring process system of the present invention will be described with reference to the drawings. In each figure, the phrase “advanced or factoring” may be abbreviated as “advanced / factoring”.
Hereinafter, the insurance claimant is not particularly limited as long as it is a person who uses the above-described medical insurance or a person who uses a care insurance. For example, there are medical institutions that can use medical insurance, dental clinics, pharmacies, osteopaths, physical therapy clinics, occupational therapy clinics, and the like. There are also nursing care providers, physical therapy clinics, occupational therapy clinics, etc. where care insurance is available. In the insurance claim processing utilized by these insurance claimants with respect to the insurance claim, the system is an extended system, particularly for replacement or factoring processing.
In addition, for those who are described as osteopathy in the above, it is used as a general term for those who can make insurance payments regarding the Acupuncture Clinic, Anma Massage Clinic, etc. in addition to the Osteopathic Clinic.
Insurers are local governments (National Health Insurance, etc.) and companies, etc. (Health Insurance Unions, etc.), and patients are patients who are insured, such as National Health Insurance, Health Insurance Associations, etc.
Further, hereinafter, the term “financial institution” is used as a general term including financial institutions such as banks and credit unions as well as non-bank institutions such as credit companies and funds.

FIG. 1 is a diagram simply showing the basic configuration of an insurance replacement processing or insurance factoring processing system 100 according to the present invention.
In this configuration example, an insurance claimant terminal 200 used by a person who makes a medical insurance claim or a care insurance claimant, an examination terminal 300 used by a receipt examination organization, and a financial system 500 used by a financial institution. It is shown. Insurance claimant terminal 200 includes a receipt creation application 210. In addition, although description is abbreviate | omitted about the network environment required for data communication, those environments shall be prepared. Also, description of processing such as ID and password required for login is omitted.
Also, as a premise, in the insurance claimant, the insured person is provided with necessary services such as medical care and nursing care, and the insurance claimant creates receipt data by using the receipt creation application 210 of the insurance claimant terminal 200. It is assumed that an intermediary of the receipt processing is requested through the insurance replacement processing or insurance factoring processing system 100 of the present invention.

  Prior to the description of the insurance replacement process or insurance factoring processing system 100 of the present invention, the insurance claimant terminal 200, the examination terminal 300, the insurer terminal 400, and the financial institution system 500 shown in FIG. 1 will be described.

  The insurance claimant terminal 200 is a computer terminal installed in a medical institution, a treatment facility, a nursing care facility, or the like. The insurance claimant terminal 200 may be a so-called stationary computer or a so-called portable hand-held computer carried by a judo reduction teacher. In recent years, a terminal used as a game machine can also be used as a small and portable computer system by installing an application. An application can be provided by an ASP (Application Service Provider).

The insurance claimant terminal 200 includes a receipt creation application 210, a patient information database 220, an insurance information database 230, replacement or factoring request means 240, and a settlement information database 250.
The interface includes an input device, an output device, a display device, etc., but is not shown in FIG.

  The receipt creation application 210 is a part that creates receipt data from the treatment contents input via the input device. In order to create a receipt as accurately as possible, the service content provided by the service provider is input to the insurance claimant terminal 200 to create receipt data. The receipt creation application 210 accesses the patient information database 220 and the insurance information database 230 and creates a receipt using necessary information.

The patient information database 220 stores various information for each patient, and stores various information indicating patient attributes such as a patient's name, address, age, and insurance number. Biometric information can also be used as patient ID information. For example, finger vein pattern information, fingerprint information, palm vein pattern information, voiceprint pattern information, iris pattern information, and the like, and their combination pattern information can also be used.
Treatment and care are performed based on the treatment plan and care plan. Such treatment plans and care plans are also managed as patient information. It also manages proxy application data that is required to apply for medical expenses. When the person who manages the insurance reimbursement process or the insurance factoring process system 100 is in the form of mediating the insurance payment request to the insurer, a resilience right as the re-agent representing the manager is required. The resubstitution application data is also managed.

  The insurance information database 230 includes basic information on local governments and other companies (information on insured persons), basic information on medical institutions and dispensing pharmacies such as hospitals (information on approval applications, etc.), and the Ministry of Health and Welfare at the time of law revision Stores information necessary for calculating medical fees issued by. The receipt creation application 210 accesses and refers to the insurance information database 230 when creating the receipt data.

  The reimbursement or factoring requesting means 240 is a reimbursement for temporarily reimbursing the insurance reimbursement party for part or all of the amount of the insurance payment requested for the insurance reimbursement or insurance factoring processing system 100, or This is a function for requesting a factoring process in which money is transferred by transferring a part or all of a medical treatment fee or a nursing care fee. The flow of the replacement or factoring request process will be described later.

  The settlement information database 250 is a database that accumulates settlement information related to insurance payment claims. It is also preferable to store deposit / withdrawal data of an account in a financial institution.

  Next, the examination terminal 300 is a terminal used by an examination organization that receives a request from an insurer and entrusts examination of a receipt.

  The insurer terminal 400 is a system installed and managed by insurers of local governments (National Health Insurance, etc.) and companies (Health Insurance Associations, etc.). The validity of the received receipt data is examined, and insurance payment processing is performed according to the receipt data whose validity is confirmed. The flow of insurance payment processing will be described later.

  The financial institution system 500 is a terminal installed by a financial institution having a settlement processing function and a replacement function capable of switching payments such as medical expenses. The financial institutions here may include non-bank institutions such as credit companies and funds in addition to banks and credit unions. The advancement or factoring process is taken over by the financial institution system 500 of the insurance advancement process or insurance factoring processing system 100 financial institution, and bears a time lag until insurance payment.

The insurance replacement processing or insurance factoring processing system 100 will be described.
As shown in FIG. 1, the insurance reimbursement processing or insurance factoring processing system 100 of the present invention includes a receipt data input means 110, a replacement or factoring processing means 120, an insurance claimant database 130, and an insurance payment processing means 140. Yes.
In this configuration example, the receipt data input means 110 includes an insurance claim amount input means 111, and the advance or factoring processing means 120 includes an advance or factoring selection means 121, an advance or factoring desired amount input means 122, an advance or factor. The apparatus includes a factoring upper limit rate setting unit 123, a replacement or factoring fee rate setting unit 124, a replacement or factoring simulation unit 125, a replacement or factoring availability determination unit 126, and a replacement or factoring determination unit 127.

Hereinafter, the configuration of the insurance replacement process or the insurance factoring processing system 100 will be described.
The receipt data input unit 110 has a function of receiving receipt data related to insurance payment request from the insurance payment requester terminal 200.
The receipt data input unit 110 includes an insurance payment claim amount input unit 111.
The receipt data input means 110 knows who is the insurance claimant for the current transaction and how much the insurance payment claim amount is based on the received receipt data. Information on the insurance payment request amount is input to the insurance payment request amount input means 111.
After the receipt data input means 110 grasps necessary information from the receipt data, the receipt data is transferred to the insurance payment request processing means 140, and the insurance payment request processing means 140 sends the receipt data to the examination terminal 300 used by the receipt examination organization. By receiving the receipt data, a receipt process, that is, an insurance payment request process is executed.
Note that the receipt data may be transmitted to the examination terminal 300 at a timing where transmission is executed regardless of progress of the replacement or factoring process described later, or transmission is performed after the replacement or factoring process described later is completed. Operation that does is also acceptable.

The advancement or factoring processing means 120 is a reimbursement in which a part or all of the amount of the insurance claim requested for insurance is temporarily reimbursed and paid in advance to the insurance claimant, or a part or all of the receivable of the medical treatment fee or the nursing care fee. This is a function for executing factoring processing for transferring money by transfer.
In order to use the replacement or factoring processing unit 120 for the replacement or factoring processing, the replacement or factoring processing unit 120 has various sub-functions.

  The reimbursement or factoring selection means 121 is a function that allows an insurance claimant who uses the insurance reimbursement process or insurance factoring process system 100 of the present invention to select whether or not he wants reimbursement process or factoring process. . In this example, the insurance reimbursement processing or insurance factoring processing system 100 of the present invention is interposed between the insurance claimant terminal 200 and the examination terminal 300 and mediates insurance claim processing for charging the insurer. For example, although it is a premise that the receipt processing of all cases is mediated from the insurance claimant terminal 200, the insurance claimant may not always want replacement or factoring for all cases. Therefore, in this configuration example, the replacement or factoring selection means 121 is provided to allow the insurance claimant to select whether the replacement process or the factoring process is desired or not. The replacement or factoring processing means 120 continues the process for executing the replacement or factoring process only when a request for replacement or factoring processing is input via the replacement or factoring selection means 121. Alternatively, the replacement or factoring process execution process by the factoring processing unit 120 is not started.

The reimbursement or factoring desired amount input means 122 is a function of accepting an input of a reimbursement or factoring desired amount desired in the current transaction to the insurance payer terminal 200. For example, an input screen for the desired amount of replacement or factoring is presented on the monitor of the insurance claimant terminal 200 via the communication network, and the desired amount of replacement or factoring is input.
In addition, the amount to be reimbursed or factored is within the amount of money for this insurance claim. However, the insurance reimbursement process or insurance factoring processing system of the present invention sets the reimbursement or factoring upper limit rate and the reimbursement or factoring fee rate as follows in consideration of the collection risk when performing the reimbursement or factoring process.

  The advance or factoring upper limit rate setting means 123 is a function for setting the advance or factoring upper limit rate for the insurance payment amount for each insurance claimant or for each transaction of the advance or factoring process. That is, an upper limit is set for how much advance payment is made for the insurance claim amount, that is, how much advance or factoring is performed. For example, assuming that the insurance claim amount for the current transaction is 100,000 yen, assuming that the replacement or factoring upper limit rate is 80%, replacement or factoring processing up to 80,000 yen is permitted.

  As will be described later, this replacement or factoring upper limit rate is not fixed and can be changed according to the situation. The reimbursement or factoring cap rate incorporates the insurance collection risk. In the first embodiment, the replacement or factoring upper limit rate setting means 123 sets the total amount of insurance claim processing, the return rate of the past claims of the insurance claimant, the insurance payment in setting the replacement or factoring upper limit rate. It can be calculated taking into account the credit information of the claimant. Depending on the insurance claimant, the receipt creation process may be unfamiliar and the receipt return rate may be high. In addition, there is a case where a receipt for insurance claim is created even though the insurance system is not well understood and an uninsured service has been provided. Since the occurrence probability of such an event often varies depending on the type of the insurance claimant, a replacement or factoring upper limit rate may be set for each insurance claimant. On the contrary, the insurance or insurance factoring processing system 100 of the present invention has a large number of uses, and the insurance or creditor has a long history of use. It may be set.

  The insurance claimant database 130 stores return rates and credit information of past receipts for each insurance claimant, and the replacement or factoring upper limit rate setting means 123 accesses the insurance claimant database 130 for replacement or Extract the information necessary for setting the factoring upper limit rate and set the replacement or factoring upper limit rate. There is no limitation on how to set the replacement or factoring upper limit rate by incorporating the return rate and credit information of the past receipt for each insurance claimant, and various calculation formulas can be adopted.

  Furthermore, the turnover or factoring upper limit rate can be determined according to the contents of the transaction. While various services are provided at medical institutions, treatment centers, and nursing care establishments, if the service appears frequently as a routine work, the content is familiar to the creation of a receipt, so there is a probability that a receipt will be returned. Although it is low, it can be said that when an unusual service that is rarely used or an irregular service is provided, the creation of the receipt is inevitably unfamiliar, and the probability of receipt return increases. It is also possible to create a receipt without realizing that it was a service that was provided as an insurance target but was not covered by the insurance. That is, the receipt return rate varies depending on the contents of the transaction as well as the insurance claimant. Therefore, the replacement or factoring upper limit setting means 123 can be determined according to the contents of the transaction.

  Next, the advance or factoring fee rate setting means 124 is a function for setting the advance or factoring fee rate for each transaction of the advance or factoring process. This reimbursement or factoring fee rate can be determined for each insurance claimant as with the reimbursement or factoring upper limit rate described above. Further, as with the above-mentioned advance or factoring upper limit rate, it is also possible to adjust the advance or factoring fee rate according to the type and content of the transaction.

  The advance or factoring simulation means 125 is a function of simulating the execution result of the advance or factoring process applied to the desired amount of advance or factoring for the insurance claimant. Before the fixed or factoring desired amount input means 122 is finalized and inputted through the fixed or factored desired amount input means 122, the input of the desired replacement or factoring amount is received for a trial, and the replacement or factoring is simulated. For example, based on the insurance claim amount, the advance or factoring ceiling rate, the advance or factoring fee rate, the amount paid early by the advance or factoring execution to the insurance claimant and the insurance payment from the insurer It is equipped with a function to calculate the settlement amount to be settled after the payment.

  The change or factoring availability determination means 126 is a function for determining whether to allow change or factoring execution. If the desired amount of advancement or factoring entered by the insurance claimant is less than or equal to the amount of the insurance claim amount multiplied by the advancement or factoring ceiling rate, the advancement or factoring execution is permitted.

  The replacement or factoring determination means 127 is a function for determining execution of replacement or factoring processing for each insurance claim processing according to the determination of the replacement or factoring availability determination means 126. A function is also provided for calculating and notifying the amount or fee provided to the insurance claimant as the advance or factoring is executed, and the transfer amount data calculated by the advance or factoring determining means 127 is used as the financial institution of the financial institution. It is also possible to operate to notify the engine terminal 300.

  The replacement or factoring processing means 120 makes use of the sub-function as described above, and temporarily or partially replaces all or part of the amount of the insurance payment requested for insurance payment to advance payment to the insurance claimant or medical treatment. A factoring process is performed in which money is transferred by transferring a part or all of the reward or care reward.

  The insurance claimant database 130 is a database that accumulates various information related to the insurance claimant, including the name of the insurance claimant, credit information, and a past receipt return rate.

  The insurance payment request processing means 140 transmits the receipt data received via the receipt data input means 110 to the insurer terminal 400 or the examination organization terminal 300 used by the examination organization designated by the insurer, and performs the insurance payment request processing. It is a function to perform.

  With the above configuration, the insurance reimbursement processing or insurance factoring processing system 100 according to the present invention executes the receipt data mediation processing by the insurance payment request processing means 140, while the entire amount or one of the amounts related to the insurance payment claims of the mediated receipt. The replacement or factoring processing unit 120 executes replacement or factoring processing.

Next, the flow of receipt data intermediation processing and replacement or factoring processing using the insurance replacement processing or insurance factoring processing system 100 of the present invention having the above-described configuration will be described.
Note that the following flow is an example, and depending on the operation, a part of the processing in the flow can be omitted or added, or the order of a part of the flow can be changed.
Moreover, the example of the various screens displayed on the insurance claimant terminal 200 is an example, and the screen design and the input items to be displayed are not particularly limited.

The insured person receives necessary services such as medical care, treatment, and care, and the insurance claimant creates the receipt data using the receipt creation application 210 of the insurance claimant terminal 200.
As shown in FIG. 2, the receipt creation application 210 of the insurance claimant terminal 200 transmits the created receipt data to the insurance reimbursement process or the insurance factoring processing system 100, and the receipt data input means 110 receives the receipt data. (Step S1).
The insurance payment request amount input means 111 of the receipt data input means 110 obtains insurance payment request amount data relating to the current transaction from the receipt data (step S2).

  As shown in FIG. 2, the receipt data input via the receipt data input means 110 is passed to the insurance payment processing means 140, and the examination used by the insurer terminal 400 or the examination organization used by the insurer according to the operation. It is transmitted to the terminal 300 (step S3).

Next, as shown in FIG. 3, the advance or factoring processing means 120 confirms whether or not to perform the advance or factoring process with the insurance claimant through the advance or factoring selection means 121. A selection screen as to whether or not to request change or factoring processing is displayed on the terminal 200 (step S4).
FIG. 4 is an example of a replacement or factoring selection screen. In the example of FIG. 4, it is a simple check box as to whether or not replacement or factoring is desired.

The insurance claimant selects whether to request a change or factoring process via the selection screen displayed on the insurance claimant terminal 200.
If it is selected not to require the replacement or factoring process (step S5: N), the process of the replacement or factoring process ends (step S6).
Here, requesting is selected (step S5: Y).

  Next, in response to a request for advancement or factoring processing, as shown in FIG. 5, the advancement or factoring desired amount input means 122 is an input screen for the amount desired to be replaced or factored in the current transaction on the insurance payer terminal 200. Is displayed (step S7).

  Further, the advance or factoring upper limit rate setting means 123 displays the advance or factoring upper limit rate of the current transaction on the insurance payer terminal 200 (step S8). For example, it is assumed that the replacement or factoring upper limit rate is determined according to the contents of the current transaction. The replacement or factoring upper limit rate setting means 123 accesses the insurance claimant database 130 as necessary to acquire information necessary for calculating the replacement or factoring upper limit rate.

  Further, the advance or factoring fee rate setting unit 124 displays the advance or factoring fee rate of the current transaction on the insurance payer terminal 200 (step S9). For example, it is assumed that the advance or factoring fee rate is determined according to the contents of the current transaction. The advance or factoring fee rate setting unit 124 accesses the insurance claimant database 130 as necessary to obtain information necessary for calculating the advance or factoring fee rate.

FIG. 6 shows an example of a screen for inputting the desired amount for replacement or factoring. In the example of FIG. 6, a replacement or factoring desired amount input column, a total insurance claim amount for the current transaction, a replacement or factoring upper limit rate, and a replacement or factoring fee rate are displayed together.
In the example of the reimbursement or factoring desired amount input screen shown in FIG. 6, the total amount of insurance claims is expressed as the length of the vertical axis along with the amount, and the reimbursement or factoring upper limit rate together with the number It is shown in the form of overlapping lines on the vertical axis of the total amount charged. In addition, the reimbursement or factoring fee rate is shown numerically.

Further, in this example, a simulation bar for the advance or factoring desired amount is prepared, and a function for simulating the execution result of the advance or factoring process applied to the advance or factoring desired amount is also provided (step S10). .
When the simulation bar of the desired replacement or factoring amount shown in FIG. 6 is dragged up and down with the mouse, the result of the replacement or factoring simulation is displayed. Items that are important to the claimant as a result of the advancement or factoring simulation are settled after the insurer's insurance payment has been executed and how much the early acquisition amount can be obtained early by the advancement or factoring execution. It is a point how much the settlement money is paid. For example, the early acquisition amount is paid the next day, and the settlement is 3 months later.

As an example, assume that the total amount of insurance claims in this transaction is 1 million yen, the replacement or factoring ceiling rate is 80%, and the replacement or factoring fee rate is 10%.
FIG. 7A is a diagram showing a simulation result when the simulation bar is adjusted to 80% of the upper limit. The desired amount for replacement or factoring is set at 800,000 yen.
The early acquisition amount that the insurance claimant can quickly obtain by replacement or factoring is 1 million yen x 80% x (1-0.1) = 720,000 yen.
The settlement is 1 million yen x (100% -80%) = 200,000 yen.
The total amount received is 920,000 yen, but 720,000 yen can be obtained early.

FIG. 7B is a diagram showing a simulation result when the simulation bar is adjusted to 70%. The desired amount for replacement or factoring is set at 700,000 yen.
The early acquisition amount that the insurance claimant can quickly obtain by replacement or factoring is 1 million yen x 70% x (1-0.1) = 630,000 yen.
The settlement is 1 million yen x (100% -70%) = 300,000 yen.
The total amount received is 930,000 yen, but 630,000 yen can be obtained early.

FIG. 7C is a diagram showing a simulation result when the simulation bar is adjusted to 50%. The desired amount for replacement or factoring is set at 500,000 yen.
The early acquisition amount that the insurance claimant can quickly obtain by performing replacement or factoring is 1 million yen × 50% × (1−0.1) = 450,000 yen.
The settlement is 1 million yen x (100% -50%) = 500,000 yen.
The total amount received is 950,000 yen, but 450,000 yen can be obtained early.

In this way, the insurance claimant can simulate the amount of money received and determine the amount to be replaced or factored in consideration of the early acquisition required for management and the total amount received.
In this example, as shown in FIG. 8, it is assumed that the insurance claimant has input the desired replacement or factoring amount of 720,000 yen according to the simulation result of FIG. 7B (step S11).

  Next, the advancement / factoring determination means 126 checks whether the advancement or factoring desired amount input by the insurance claimant is equal to or less than the amount obtained by multiplying the insurance claim amount by the advancement or factoring upper limit rate. (Step S12) If the requirement is satisfied (Step S12: Y), the change or factoring availability determination means 126 permits the change or factoring execution (Step S13). If the requirement is not satisfied (step S12: N), the replacement or factoring availability determination means 126 does not permit the replacement or factoring execution, and inputs the desired replacement or factoring amount to the insurance payer terminal 200 again. Display a message (return to step S10).

The advance or factoring determination means 127 calculates the amount provided to the insurance claimant as the advance or factoring is executed, and notifies the examination organization terminal 500 of information relating to the advance or factoring (step S14). In this example, the advance or factoring determination means 127 notifies the financial institution terminal 300 of the desired amount of change or factoring of 800,000 yen and the transfer amount data of 720,000 yen minus the fee.
The financial institution terminal 300 receives the notification from the insurance replacement process or the insurance factoring processing system 100, and executes the replacement or factoring (step S15).

  Through the above flow, the insurance reimbursement process or the insurance factoring processing system 100 is used to mediate the receipt process created by the insurance claimant terminal 200, and the insurance payment claim settlement process is financed by reimbursement or factoring process. It is taken over by the financial institution terminal 300 of the institution and allows the financial institution to bear the burden of time lag until insurance payment is completed.

In addition, regarding the advance or factoring process executed in the intermediary process of the insurance payment claim process performed in the past, it is possible to devise permitting the past advance or changing the desired factoring amount within a predetermined period.
The insurance claimant terminal 200 applies to the insurance reimbursement process or the insurance factoring processing system 100 for a request for changing the past reimbursement or factoring desired amount. There are various ways to express this intention.

  For example, every time the insurance reimbursement process or the insurance factoring processing system 100 performs the reimbursement or factoring execution process, a transaction ID number is issued and notified to the insurance payer terminal 200. There is an operation in which a number is entered and notified to the insurance replacement process or the insurance factoring processing system 100 to make a request for changing the past replacement or factoring desired amount.

  In addition, for example, a list that has undergone receipt mediation between the insurance reimbursement process or the insurance factoring processing system 100 and the insurance claimant terminal 200 can be displayed in units of weeks, months, seasons, years, etc. Clicking on an item in the period in which a change or factoring desired amount change request is possible from the inside, there are operations such as transition to the change or factoring desired amount change request screen, etc., as a past change or factoring desired amount change request .

  In addition, for example, by retransmitting receipt data that has been replaced or factored in the past from the receipt creation application 210, the relevant matter is identified from the date or receipt ID number that the replacement or factoring processing means 120 has processed in the past. However, there are operations that require a change or request to change the factoring amount.

In the request for change of the amount to be replaced or factored, in the intermediary processing of the insurance claim processing performed in the past, for the request for replacement or factoring processing was not selected via the replacement or factoring selection means 121, the replacement or factoring It also includes allowing the desired change and performing a turnover or factoring process.
In other words, for the case specified in the request for change of the advancement or factoring desired amount, for the case for which advancement or factoring processing has not been desired in the past, the advancement or factoring selection means 121 again performs the change or change as shown in FIG. A selection screen for determining whether or not factoring is desired may be displayed on the monitor of the insurance claimant terminal 200.

FIG. 11 is a diagram simply illustrating a screen for changing a case for which past change or factoring processing is not desired.
As shown in the upper diagram of FIG. 11, in the intermediary process of the insurance claim processing performed in the past, if the request for replacement or factoring processing is not selected via the replacement or factoring selection means 121, within a predetermined period. For example, as shown in the lower diagram of FIG.
As shown in the lower diagram of FIG. 11, if a change to be replaced or factored is accepted, the desired replacement or factoring amount input means 122 again inputs the desired amount of replacement or factoring. The amount input screen is displayed on the monitor of the insurance claimant terminal 200, and a simulation as shown in FIG. 7 can be used.

FIG. 12 is a diagram simply showing a screen for changing the desired replacement or factoring amount for a case where past replacement or factoring processing has been executed.
For example, as shown in the upper diagram of FIG. 12, it is assumed that there is a transaction determined by inputting the advance or factoring utilization rate as 70% on the past advance or factoring desired amount input screen. If it is recognized that a request for change of the advance or factoring amount has been input, the advance or factoring amount input means 122 causes the advance or factoring amount input means 122 to be input again for the case where the advance or factoring process has been executed in the past. 12, a replacement or factoring desired amount input screen as shown in the lower diagram of FIG. 12 is displayed on the monitor of the insurance claimant terminal 200.
If it is within the predetermined period, the use of the simulation as shown in FIG. 7 is also permitted. As a result, as shown in the lower diagram of FIG. 12, the change or factoring usage rate is entered and determined on the input screen for the desired change or factoring amount. be able to. Here, it is determined by inputting as a replacement or factoring utilization rate of 80%. In this case, the difference of 90,000 yen is paid to the user by replacement or execution of factoring.

If there is a change in the advance or factoring execution amount due to a change in the advance or factoring desired amount, an amount of money will be exchanged between the insurance claimant and the person who made the advance or factoring (financial institution). When the advance or factoring amount is increased, the advance payment for the difference is paid from the financial institution to the insurance claimant. Conversely, if the advance or factoring amount is reduced, the amount of the difference will be returned from the insurance claimant to the financial institution.
In the request for change of the advance or factoring amount, there may be a case where the advance or factoring use amount is set to 0 and the use of the change or factoring is stopped with respect to an item that has undergone advance or factoring execution in the past. This means that the entire amount of insurance claims received in advance by replacement or factoring will be returned to the financial institution. Fees related to reimbursement or factoring processing executed by financial institutions in the past can be determined in detail.

  In the second embodiment, regarding the setting of the replacement or factoring upper limit rate and the setting of the replacement or factoring fee rate, the type of the receipt creation application 210 of the insurance claimant terminal 200 and the expected examination pass rate calculated by the receipt creation application 210 are taken into account. This is an example.

FIG. 13 is a diagram simply illustrating a configuration of an insurance replacement process or insurance factoring processing system 100a according to the second embodiment.
Comparing FIG. 13 and FIG. 1, the receipt data input means 110a of the insurance reimbursement process or insurance factoring processing system 100a includes the expected examination pass rate input means 112a, the receipt creation application recognition in addition to the insurance payment request amount input means 111a. Means 113a is added.

The examination pass expectation rate input means 112a is a function for inputting the examination pass expectation rate of the receipt data determined by the receipt creation application 210a that created the receipt data at the insurance claimant terminal.
The expected receipt rate of examination of the receipt data is a self-determined numerical value indicating how much the created receipt data has been created as a function of the receipt creation application 210a used by the insurance claimant terminal 200a. is there.

  The ordinary receipt creation application only creates and outputs a receipt based on the data input by the insurance claimant. However, the receipt creation application planned to be provided by the applicant, LEIS, When a receipt is created based on data input by a payment requester, a “probability of passing examination” is calculated, which is the probability of the receipt passing the examination by the receipt examination body. The insurance reimbursement process or the insurance factoring processing system 100a uses the expected examination pass rate.

By using the expected rate of passing the examination, the risk of the receipt failing the receipt examination and making it impossible to collect the insurance amount, or delaying the collection of the insurance amount through amendments and other procedures after return is incorporated. Can do.
For example, if there is no problem with the date and time of service provision for the contents of a routine work for a care recipient that has been passed many times in the past, there is no problem with the date and time of service provision. The nature is extremely low. In such a case, it can be calculated assuming that the examination pass expectation rate is almost 100%.

  On the other hand, when a variety of services are provided at medical institutions, treatment centers, and nursing care establishments, if an unusual service that is rarely used or an irregular service is provided, the creation of the receipt is unavoidable, and the receipt is returned. It can be said that there is a high probability of occurrence. It is possible to create a receipt without realizing that it was a service that was provided as an insurance target but was not covered by the insurance. In addition, the receipt return rate varies depending on the content of the transaction, such as when there is a doubt about the travel time of the caregiver of the visiting caregiver. The receipt creation application 210a can digitize such various situations as an examination pass expectation rate. How to calculate the examination pass expectation rate can be variously calculated and is not particularly limited here.

  In the second embodiment, the receipt creation application 210 a transmits not only the created receipt data but also the calculated examination pass expectation rate to the receipt data input unit 111. The examination pass expectation rate input unit 112a acquires numerical data of the examination pass expectation rate and notifies the change or factoring upper limit rate setting unit 123 and the change or factoring fee rate setting unit 124.

The advance or factoring upper limit rate setting means 123 and the advance or factoring fee rate setting means 124 respectively set the advance or factoring upper limit rate and the return or return rate of the past receipt for each insurance claimant in setting the advance or factoring fee rate. In addition, the replacement or factoring upper limit rate and the replacement or factoring fee rate are set by incorporating credit information and credit information, and further, the calculation using the examination pass expectation rate can be performed.
The replacement or factoring upper limit setting means 123 sets the replacement or factoring upper limit for a transaction with a high examination pass expectation rate, and conversely sets the replacement or factoring upper limit for a transaction with a lower examination pass expectation rate. good.

  The replacement or factoring fee rate setting means 124 sets a low replacement or factoring fee rate for a transaction with a high expected examination pass rate, and conversely sets a high replacement or factoring fee rate for a transaction with a low expected pass rate. Just do it.

Next, the receipt creation application recognition unit 113a will be described.
The receipt creation application recognition unit 113a is a function that automatically recognizes the type of the receipt creation application 210a used in the insurance claimant terminal 200a.
Whether or not the receipt passes the examination at the receipt examination organization without any problem and the insurance payment is executed is influenced by the type of the receipt creation application 210a. In general, it can be said that there is a difference in the performance of software depending on the manufacturer, version, and installed database. After all, an excellent receipt creation application 210a created by an excellent software provider supports stable and accurate receipt data creation, and there is a high probability that correct receipt data will be created, but there are many problematic receipt creations. If it is application 210a, it is unstable and the probability of a receipt return may become large.

  Accordingly, the receipt creation application recognition unit 113a accesses the insurance reimbursement process or the insurance factoring processing system 100a, and is used by the counterpart insurance claimant terminal 200a that has transmitted the receipt data via the receipt data input unit 111. Information about the type and version of the receipt creation application and the environment of the on-board database is extracted from the receipt data or collected individually by exchanging with the receipt creation application 210a.

The replacement or factoring upper limit rate setting means 123 adjusts the replacement or factoring upper limit rate according to the environmental conditions such as the type, version, and installed database of the receipt creation application, or the replacement or factoring fee rate setting means 124 sets the replacement or factoring. Adjust the commission rate.
The replacement or factoring upper limit rate setting means 123 sets a higher replacement or factoring upper limit for transactions involving the stable receipt creation application 210a with few problems in the past, and conversely, those having many problems in the past, new products or new For transactions involving a receipt creation application 210a that has not yet been demonstrated to be stable, such as a version, the replacement or factoring upper limit may be set low.

  Similarly, the advance or factoring fee rate setting means 124 sets a lower substitute or factoring fee rate for transactions involving the stable receipt creation application 210a with less problems in the past, and vice versa. For transactions involving a receipt creation application 210a that has not yet been demonstrated to be stable, such as a new product or a new version, a high rate of replacement or factoring fee may be set.

The processing steps of the insurance replacement processing or insurance factoring processing system according to the present invention are described as a computer program, and are provided in a form carried on a computer-readable storage medium or downloaded via a computer network. Can do.
In addition, the insurance reimbursement processing or insurance factoring processing system according to the present invention can be used as an ASP via a network.

  As described above, the preferred embodiment in the configuration example of the insurance replacement processing or insurance factoring processing system of the present invention has been illustrated and described, but it is understood that various modifications can be made without departing from the technical scope of the present invention. Will be done.

  The insurance reimbursement processing or insurance factoring processing system of the present invention is used by medical institutions, dental clinics, pharmacies, osteopaths, acupuncture clinics, Anma massage clinics, physical therapy clinics, occupational therapy clinics, etc. that can use medical insurance, or nursing care insurance It can be widely applied to systems related to insurance claims used by nursing care providers, physical therapy clinics, occupational therapy clinics and the like.

DESCRIPTION OF SYMBOLS 100 Insurance replacement process or insurance factoring processing system 110 Receipt data input means 111 Insurance payment request amount input means 112 Examination pass expected rate input means 113 Receipt creation application recognition means 120 Replacement or factoring processing means 121 Replacement or factoring selection means 122 Replacement or factoring Desired amount input means 123 Replacement or factoring upper limit rate setting means 124 Replacement or factoring fee rate setting means 125 Replacement or factoring simulation means 126 Replacement or factoring availability determination means 127 Replacement or factoring determination means 130 Insurance claimant database 140 Insurance claim processing Means 150 Communication function 200 Insurance claimant terminal 210 Receipt creation application Shon 220 patient information database 230 insurance information database 240 advances or factoring request unit 250 settlement information database 260 communication function 300 examination terminal 400 insurer terminal 500 Financial System

Claims (12)

Regarding insurance claim processing for medical insurance or long-term care insurance, the claimant terminal used by the person who makes the insurance claim for medical insurance or the claimant for the long-term care insurance, the insurer terminal used by the insurer, and the receipt It intervenes with the examination terminal used by the examination body, mediates insurance claim processing for making an insurance claim to the insurer, and temporarily changes part or all of the insurance claim amount to An insurance reimbursement process or an insurance factoring process system for executing a reimbursement process to be paid in advance to an insurance claimant or a factoring process for transferring money by transferring a part or all of a medical treatment fee or a nursing care fee,
Insurance payment amount input means for receiving input of the insurance payment amount based on the receipt data related to the insurance payment request from the insurance claimant terminal;
Reimbursement or factoring desired amount input means for accepting input of desired reimbursement or factoring desired amount for the insurance claim amount from the insurance claimant terminal;
An advance or factoring upper limit setting means for setting an advance or factoring upper limit for the insurance claim amount for each insurance payer or for each transaction of the advance or factoring process;
A replacement or factoring determination unit is provided for permitting replacement execution or factoring execution when the desired amount for replacement or factoring is equal to or less than an amount obtained by multiplying the insurance claim amount by the replacement or factoring upper limit rate. Insurance reimbursement processing or insurance factoring processing system. Comprising an advance or factoring fee rate setting means for setting an advance or factoring fee rate for each transaction of the advance or factoring process;
The insurance reimbursement process or insurance factoring process system according to claim 1, wherein the reimbursement or factoring upper limit rate and the reimbursement or factoring fee rate are presented to the insurance payer terminal. Each insurance claimant comprises an insurance claimant database in which past receipt return rates and credit information are stored;
In the setting of the replacement or factoring upper limit rate, the replacement or factoring upper limit rate setting means sets the total amount of the insurance claim processing to be processed, the return rate of the past claim of the insurance claimant, and the insurance claimant. The insurance reimbursement processing or insurance factoring processing system according to claim 2, wherein the calculation is performed in consideration of the credit information of the insurance. An expected examination pass rate input means for receiving an expected assessment pass rate of the receipt data determined by the application that created the receipt data at the insurance claimant terminal;
4. The insurance replacement processing or insurance factoring processing system according to claim 3, wherein the replacement or factoring upper limit rate setting means adjusts the replacement or factoring upper limit rate in accordance with the examination pass expectation rate. A receipt creation application recognition means for recognizing environmental conditions including the type, version and installed database of the application for which the claimant terminal created the receipt data;
The insurance replacement processing or insurance factoring processing system according to claim 3 or 4, wherein the replacement or factoring upper limit rate setting means adjusts the replacement or factoring upper limit rate according to a type of the receipt creation application. An expected examination pass rate input means for receiving an expected assessment pass rate of the receipt data determined by the application that created the receipt data at the insurance claimant terminal;
4. The insurance replacement processing or insurance factoring processing system according to claim 3, wherein the replacement or factoring fee rate setting means adjusts the replacement or factoring fee rate in accordance with the expected examination pass rate. A receipt creation application recognition means for recognizing environmental conditions including the type, version and installed database of the application for which the claimant terminal created the receipt data;
7. The insurance replacement processing or insurance factoring processing system according to claim 3 or 6, wherein the replacement or factoring fee rate setting means adjusts the replacement or factoring fee rate according to a type of the receipt creation application. The insurance claim amount input means accepts provisional input of the insurance claim amount from the insurance claimant terminal,
The reimbursement or factoring desired amount input means accepts temporary input of the reimbursement or factoring desired amount from the insurance claimant terminal,
Simulation means for presenting to the insurance claimant terminal a simulation result including the result of the determination of whether or not to accept the replacement or factoring based on the insurance claim amount for the provisional input and the desired amount for replacement or factoring, and the amount to be paid The insurance reimbursement processing or insurance factoring processing system according to any one of claims 1 to 7, further comprising:   If the advance or factoring process executed in the intermediary process of the insurance claim process performed in the past is within a predetermined period, the past change or factoring desired amount via the desired replacement or factoring amount input means The insurance reimbursement processing or insurance factoring processing system according to any one of claims 1 to 8, wherein a change is permitted, and a replacement or factoring processing for a difference amount can be executed. A replacement or factoring selection means for causing the insurance claimant to input a selection of whether or not to request the replacement or factoring process;
Only when a request for the replacement or factoring process is input via the replacement or factoring selection means, an acceptance screen for inputting the replacement or factoring desired amount by the replacement or factoring desired amount input means is presented. The insurance replacement processing or insurance factoring processing system according to claim 9.   In the intermediation process of the insurance claim processing performed in the past, if the request for the replacement or factoring process is not selected via the replacement or factoring selection means, the replacement or factoring selection is within the predetermined period. 10. The insurance replacement processing or insurance factoring processing system according to claim 9, wherein said replacement or factoring desired selection is permitted to be changed through means, and said replacement or factoring processing can be executed. As an intermediary process of the insurance payment request process, a receipt data input means for receiving receipt data related to the insurance payment request from the insurance payment requester terminal;
An insurance payment claim processing means for transmitting the receipt data to the insurer terminal or an examination body terminal used by an examination body designated by the insurer, and for performing an insurance payment request process;
12. A replacement or factoring determination unit that determines execution of the replacement or factoring process for each of the insurance claims processing according to the determination of the replacement or factoring availability determination unit. Insurance reimbursement processing or insurance factoring processing system as described in any one.

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