KR101873147B1 - Simulation method of insurance request using online network and the system - Google Patents

Abstract

The present invention provides a method to simulate an insurance claim and a system thereof. The method includes: a step of generating and registering a rule ID including demand information according to the approval of sickness in regard to medicine; a step of storing and registering a message when the demand information is omitted from the generated rule ID; a step of receiving the demand information according to the approval of sickness from a hospital terminal through an agent; a step of requesting the rule ID to a rule DB in accordance with the received demand information; a step of receiving the rule ID from the rule DB and comparing the demand information received from a client to check whether there is an omission from the demand information; and a step of displaying a message when there is an omission from the demand information.

Description

TECHNICAL FIELD [0001] The present invention relates to a method and system for simulating an insurance claim using an online network,

The present invention relates to a method and system for simulating insurance claims using an online network. More particularly, the present invention relates to a method and system for simulating insurance claims using an online network, The pre-examination related data is stored in the server side, and the basic data to be analyzed is stored in the index database by using the search engine. Thus, when the client needs analysis, the user can access the index created by the search engine and quickly call The present invention relates to a method and system for simulating an insurance claim that provides a preventive function or a preventive function against insufficiency, adjustment, and refund of an insurance claim amount.

The hospital, clinic, medical institution or pharmacy (hereinafter referred to as "medical provider") will treat the patient, bill the charges incurred in accordance with the medical treatment with the billing statement, and submit it to the Health Insurance Evaluation and Evaluation Service. .

In this way, the examination of the medical fee is started by the medical provider requesting the details of the medical treatment and the fee for the patient in the 'medical billing bill', which is the billing form of the medical insurance provider. You may be notified of the results of the examination by checking the claim file beforehand and requesting it directly to the Health Insurance Evaluation and Evaluation Service through the internet network.

Currently, the Health Insurance Review and Assessment Service is responsible for checking the patient's illness code, billing code, and price errors in the billing statement requested by the healthcare provider as described above. Most of the medical examinations are performed for the medical examination.

If an unexpected "adjustment" or "non-auditability" situation arises when a physician-level medical institution fails to include the essentials required to be recognized as an object of payment when an insurance claim is filed with the Health Insurance Review and Assessment Agency The insurance companies are inevitably harmed because they can not be recognized as insurance.

However, it is difficult to obtain the time and human resources to check this mistake of the input person in case of the hospital medical care institution which is not the hospital grade with dedicated examination personnel, It is not easy to know what items are not recognized and the costs have not been paid. Therefore, it is common to be in a position to accept the given results. Therefore, it is necessary to defend or prevent the adjustment of insurance claims.

The present invention has been devised to solve the problems of the existing technology as described above. The object of the present invention is to provide a health insurance notice written in a codified conditional expression, automatically code it using a program, Rules are easily created and pre-examination related data is stored on the server side, and basic data to be analyzed by using a search engine is made into an index DB. When a client needs analysis, the client accesses the index created by the search engine, The present invention provides a method and system for simulating an insurance claim that provides protection means or preventive function against insufficiency, adjustment, and refund of insurance claims.

The technical problem of the present invention as described above is achieved by the following means.

(1) generating and registering a rule ID including request information according to an authorized disease for a drug;

Storing a message for request information missing from the generated rule ID and registering the message;

Receiving request information according to an authorized disease through an agent at a hospital terminal;

Requesting a rule ID to the rule DB according to the inputted request information;

Receiving a rule ID from a rule DB and comparing whether there is any missing request information received from a client;

And displaying a message about the missing request information, if any, in the online network.

(2) In the above (1)

Wherein the demand information is a number, a disease, a medicine, a component, and a treatment material.

(3) In the above (1)

Wherein when a rule ID is requested to the rule DB according to the inputted request information, the web server refers to the index by using a search engine and searches for it.

(4) a pre-examination request data extracting unit for reading a billing statement prepared by the user and extracting pre-examination request data from the pre-examination request data, a pre-examination request data transmitting unit for transmitting the extracted pre- A rule ID receiving unit for receiving a rule ID from the rule ID receiving unit; When the rule ID receiving unit receives the rule ID from the information providing server, compares the preliminary examination request data extracted by the preliminary examination request data extracting unit with the basic information mapped to the rule ID to obtain data A client including an analysis unit, and a client analysis agent including a result display unit for displaying a result analyzed by the data analysis unit; And

A rule ID extracting unit for retrieving and extracting a specific rule ID stored in the DB storage unit using the basic information of the received pre-examination request data, a rule ID extracting unit for extracting the extracted rule ID, And an information providing server including a rule ID transmitting unit for transmitting the rule ID to the client

(5) In the above (4)

Wherein the information providing server further comprises a search engine, and the rule ID is quickly extracted by accessing the index DB generated by the search engine.

(6) A recording medium readable by a computer recording a program for executing the method for simulating an insurance claim according to any one of (1) to (3) above.

As described above, according to the present invention, the described health insurance notice is written in a conditional expression that can be coded, and the health insurance notice rule is automatically generated by automatically coding using the program, and the pre- If the client needs analysis, it can access the index created by the search engine and process it quickly, making it impossible to review, adjust, and return the insurance claim. A preventive function or a preventive function can be provided.

1 is a schematic block diagram of a simulation system for insurance claims using an online network according to an embodiment of the present invention.
2 is a diagram illustrating a detailed configuration of a client analysis agent according to an exemplary embodiment of the present invention.
3 is a diagram illustrating a detailed configuration of an information providing server according to the present invention.
4 is a schematic block diagram of a simulation system for insurance claims using an online network according to another embodiment of the present invention.
FIG. 5 is a flow chart of a process for manufacturing a health insurance notification rule according to the present invention.
6 is a flowchart of a data analysis process according to the present invention.

Hereinafter, preferred embodiments according to the present invention will be described in detail with reference to the accompanying drawings. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS The following detailed description, together with the accompanying drawings, is intended to illustrate exemplary embodiments of the invention and is not intended to represent the only embodiments in which the invention may be practiced. The following detailed description includes specific details in order to provide a thorough understanding of the present invention. However, those skilled in the art will appreciate that the present invention may be practiced without these specific details.

In some instances, well-known structures and devices may be omitted or may be shown in block diagram form, centering on the core functionality of each structure and device, to avoid obscuring the concepts of the present invention.

Throughout the specification, when an element is referred to as "comprising" or " including ", it is meant that the element does not exclude other elements, do. Also, the terms " part, "" module," and " module ", etc. in the specification mean a unit for processing at least one function or operation and may be implemented by hardware or software or a combination of hardware and software have. Also, the terms " a or ", "one "," the ", and the like are synonyms in the context of describing the invention (particularly in the context of the following claims) May be used in a sense including both singular and plural, unless the context clearly dictates otherwise.

In the following description of the present invention, a detailed description of known functions and configurations incorporated herein will be omitted when it may make the subject matter of the present invention rather unclear. The following terms are defined in consideration of the functions in the embodiments of the present invention, which may vary depending on the intention of the user, the intention or the custom of the operator. Therefore, the definition should be based on the contents throughout this specification.

Hereinafter, the contents of the present invention will be described in more detail with reference to the drawings showing embodiments.

FIG. 1 is a schematic diagram of a simulation system for insurance claims using an online network according to the present invention. The system includes a client terminal 100, an information providing server 200, a DB storage unit 300, and a network 400 .

The client terminal 100 includes a client analysis agent 110 as shown in FIG. 2, and the client analysis agent 110 is implemented as a computer program installed in the client terminal 100. The client analysis agent 110 accesses the information providing server 200 using the network 400 such as the Internet, and then downloads and installs the client.

As shown in FIG. 2, the client analysis agent 110 includes a pre-examination request data extracting unit 111 to read the billing statement created by the user and extract the pre-examination request data. At this time, it is preferable that the pre-examination request data extracting unit 111 does not include the personal information such as the patient name in the extraction process.

Preferably, the pre-examination request data includes basic information such as a number, a disease, a medicine, a treatment material, and a principal component.

The client analysis agent 110 includes a pre-examination request data transmission unit 112 for transmitting the extracted pre-examination request data to the information providing server 200. The pre-examination request data transmission unit 112 transmits the pre- 3, the pre-examination request data receiving unit 210 of the information providing server 200 receives and stores the received data in the DB storage unit 300.

Also, the client analysis agent 110 includes a rule ID receiving unit 113 that receives a rule ID from the information providing server 200. The rule ID is a unique ID that is mapped to the basic information about the number, the disease, the medicines, the treatment material, and the main component. The rule ID is a unique ID of the Tylenol (trade name), for example, specifying M0010001 as the rule ID, , The disease code B001, and the principal component code 101406ATB to the DB storage unit 300. [

The client analysis agent 110 of the present invention further includes a data analysis unit 114 as needed and when the rule ID receiving unit 113 receives the rule ID from the information providing server 200, 114 compares the pre-examination request data extracted by the pre-examination request data extracting unit 111 with the basic information mapped to the rule ID to analyze whether there is missing information.

The client analysis agent 110 displays a result analyzed by the data analysis unit 114 through a result display unit 115 in a format of a predetermined format.

3, when the pre-examination request data receiving unit 210 receives the pre-examination request data, the rule ID extracting unit 220 extracts the pre-examination request data The specific rule ID stored in the DB storage unit 300 is retrieved and extracted using the basic information of each rule ID.

4, the information providing server 200 preferably includes a search engine 310 and accesses the index DB generated by the search engine 310 to quickly extract the rule ID do. When referring to an index like this, it is possible to reduce the time required for searching accurately.

The extracted rule ID is transmitted to the client 100 by the rule ID transmitting unit 230.

The method according to the present invention is carried out from the process of producing health insurance notice rules as shown in Fig.

In step 501, the information providing server collects the new notification / drug from the evaluation evaluation website. Here, the term "new notification" refers to "the new efficacy or dosage of new medicines and the new efficacy and dosage of existing medicines are changed by the government agencies that administer medicines such as the HIRA and the Ministry of Health and Welfare" "A substance that eats, applies, or injects to repair or prevent a disease or injury". Such information can be collected through the Internet through the homepage of the Health Insurance Review and Evaluation Service (www.hira.or.kr).

In step 502, the information providing server prepares the approved annoying disease / capacity usage method / specific description / concurrent use / other matters for the new notice / drug collected in step 501 as a statement according to the notified condition standard.

In the above, the certified corporal disease is related to "a form of violation when there is no necessary corporal disease in prescription according to the notification of the efficacy of the drug", and when there is no corporal disease that must exist when the chemical exists, Create a message with

In the above, the dosage regimen is related to "a form or a dosage violating form according to the patient (age, gender, etc.) classified by the dosage regimen of the drug", and the prescription dose per day If you leave, create a message with a statement like this.

In the above, a specific description relates to "a form that is violated when the prescription exception rule described in the notification is not listed in a specific statement other than the recognized prescription," and there is a principle in the notice, If there is an error or an error, please write a message with a statement like this.

In the above, the term "combined use" refers to "when the prescribed method to be followed when mixing two or more kinds of medicines is not complied with", and when two or more kinds of medicines are administered, Check for missing drugs and write a message with a statement like this.

In addition to the above, other matters are related to "when it does not meet the prescribed conditions". If the violation of criteria that can be prescribed other than the above is violated, write a message with a statement like this.

In step 503, the information providing server creates a conditional expression that can be coded by using a predetermined program (for example, Excel) by symbolizing the statement generated in step 502 so that the result value can be output according to each code condition value.

That is, a rule ID is assigned to the new notification / medication, and the accused disease / dosage regimen / specific history / combined contraception / other matters are symbolized as A to E, respectively, As shown in Fig.

[Example]

{function. M0010001

if (E + B!) then,

"Please enter capacity usage"

end}

In step 504, the information providing server establishes a database for the authorized corporation / capacity usage method / specific statement / concurrent use / other matters for each rule ID based on the conditional expression created as in step 503 above.

In step 505, the information providing server automatically performs coding using a separate program for generating a program source with respect to the conditional expression created as described above.

In step 506, the above program source is applied to the real server.

Hereinafter, the contents of the present invention will be described in detail with reference to the data analysis process shown in FIG.

In step 601, the information providing server stores the pre-examination related data. The pre-examination related data means that it is generated by step 504 of FIG. Preferably, the pre-examination related data is structured so as to be easily retrieved. The basic data to be analyzed is extracted from pre-examination related data stored in step 504 using a search engine (for example, Solar) do.

In step 602, the server 100 receives pre-examination request data from the client 100 and stores it in the user DB. For example, the authorization cassette / capacity usage / specific details / concurrent usage / other matters entered by the user into the client are stored in the user DB as the pre-examination request data, and preferably the premium payment file format The data to be recorded in the SAM file is stored as the pre-examination request data.

In step 603, the information providing server accesses the index DB generated by the search engine using the pre-examination request data transmitted from the client by requesting analysis, and quickly extracts the rule ID.

In step 604, the information providing server performs analysis using the extracted rule ID. The analysis process may be performed by the information providing server 200 and may transmit the resultant value to the client 100, or may be performed by the client It is good to do. The client analysis agent 110 receives the rule ID from the information providing server 200 when the client 100 executes the rule ID, performs a comparison analysis using the predetermined conditional expression, and displays the resultant value to the user.

For example, when the client 100 receiving the rule ID analyzes the pre-examination request data input by the user by the client analysis agent 110 performing the process described in FIG. 6, However, if B is missing, the user is prompted to display the determined message.

According to the above method, the analysis agent of the client can process within 2 seconds for 2,000 requests for analysis.

As described above, each block of the block diagrams attached hereto and combinations of steps of the flowchart diagrams may be performed by the program instructions. These program instructions may be embedded in a processor of a general purpose digital terminal, or other programmable data processing apparatus, so that the instructions performed through these processors may be used to implement the functions described in each block or flowchart of the block diagram Respectively. These program instructions may also be stored in a digital terminal available or digital terminal readable memory capable of directing a computer or other programmable data processing equipment to implement a function in a particular manner, It is also possible for the instructions stored in the readable memory to produce an article of manufacture containing instruction means for performing the function described in each block or flowchart of each block diagram. Program instructions may also be loaded on a digital terminal or other programmable data processing equipment so that a series of operating steps may be performed on a digital terminal or other programmable data processing equipment to create a process running on the digital terminal to generate a digital terminal or other It is also possible that the instructions that perform the programmable data processing equipment provide the steps for executing the functions described in each block of the block diagram and at each step of the flowchart.

Also, each block or each step may represent a module, segment, or portion of code that includes one or more executable instructions for executing the specified logical function (s). It should also be noted that in some alternative embodiments, the functions mentioned in the blocks or steps may occur out of order. For example, two blocks or steps shown in succession may in fact be performed substantially concurrently, or the blocks or steps may sometimes be performed in reverse order according to the corresponding function.

The foregoing description is merely illustrative of the technical idea of the present invention, and various changes and modifications may be made by those skilled in the art without departing from the essential characteristics of the present invention. Therefore, the embodiments disclosed in the present invention are intended to illustrate rather than limit the scope of the present invention, and the scope of the technical idea of the present invention is not limited by these embodiments. The scope of protection of the present invention should be construed according to the following claims, and all technical ideas falling within the scope of the same shall be construed as falling within the scope of the present invention.

100: Client
200: Information providing server
300: DB storage unit
400: Network

Claims (6)

The information providing server generates a rule ID including pre-examination related data with respect to the medicine and registers the rule ID in the rule DB;
If the information providing server misses the pre-audit related data in the created rule ID, storing the message and registering the message;
The information providing server receiving the pre-examination request data from the client through the client analysis agent;
Extracting a rule ID registered in the rule DB according to the received request;
Performing an analysis using the rule ID extracted from the rule database by the information providing server and comparing whether there is any missing pre-examination request data received from the client; And
And transmitting the resultant value to the client when the information providing server is missing from the pre-examination request data. The method according to claim 1,
Wherein the pre-examination related data includes information on a number, a disease, a medicine, a component, and a treatment material information. The information providing server generates a rule ID including pre-examination related data with respect to the medicine and registers the rule ID in the rule DB;
If the information providing server misses the pre-audit related data in the created rule ID, storing the message and registering the message;
The information providing server receiving the pre-examination request data from the client through the client analysis agent;
Extracting a rule ID registered in the rule DB according to the received request and transmitting the extracted rule ID to the client;
Performing a analysis using a rule ID by the client analysis agent to compare whether there is a missing one of the preliminary examination request data; And
And if the client analysis agent is missing any of the pre-examination request data, displaying the result to the user. A pre-examination request data extracting unit for extracting pre-examination request data from the billing statement created by the user, a pre-examination request data transmitting unit for transmitting the extracted pre-examination request data to the information providing server, a rule ID A rule ID receiving unit for receiving the rule ID; When the rule ID receiving unit receives the rule ID from the information providing server, compares the preliminary examination request data extracted by the preliminary examination request data extracting unit with the basic information mapped to the rule ID to obtain data A client including an analysis unit, and a client analysis agent including a result display unit for displaying a result analyzed by the data analysis unit; And
A rule ID extracting unit for retrieving and extracting a specific rule ID stored in the DB storage unit using the basic information of the received pre-examination request data, a rule ID extracting unit for extracting the extracted rule ID, And an information providing server including a rule ID transmitting unit for transmitting the rule ID to the client. 5. The method of claim 4,
Wherein the information providing server further comprises a search engine, and the rule ID is quickly extracted by accessing the index DB generated by the search engine. A computer-readable recording medium having recorded thereon a program for executing a method of simulating an insurance claim according to any one of claims 1 to 3.

Images