WO2018179375A1 - Système pour processus d'avance d'assurance ou processus d'affacturage d'assurance - Google Patents

Système pour processus d'avance d'assurance ou processus d'affacturage d'assurance Download PDF

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Publication number
WO2018179375A1
WO2018179375A1 PCT/JP2017/013715 JP2017013715W WO2018179375A1 WO 2018179375 A1 WO2018179375 A1 WO 2018179375A1 JP 2017013715 W JP2017013715 W JP 2017013715W WO 2018179375 A1 WO2018179375 A1 WO 2018179375A1
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Prior art keywords
insurance
factoring
replacement
processing
amount
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PCT/JP2017/013715
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English (en)
Japanese (ja)
Inventor
力 松永
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株式会社Ｌｅｉｓ
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Application filed by 株式会社Ｌｅｉｓ filed Critical 株式会社Ｌｅｉｓ
Priority to PCT/JP2017/013715 priority Critical patent/WO2018179375A1/fr
Priority to JP2017535106A priority patent/JP6313529B1/ja
Publication of WO2018179375A1 publication Critical patent/WO2018179375A1/fr

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    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H40/00—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices
    • G16H40/20—ICT specially adapted for the management or administration of healthcare resources or facilities; ICT specially adapted for the management or operation of medical equipment or devices for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q20/00—Payment architectures, schemes or protocols
    • G06Q20/08—Payment architectures
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
    • G06Q40/08—Insurance
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q50/00—Information and communication technology [ICT] specially adapted for implementation of business processes of specific business sectors, e.g. utilities or tourism
    • G06Q50/10—Services
    • G06Q50/22—Social work or social welfare, e.g. community support activities or counselling services

Definitions

  • the present invention is a medical institution that can use medical insurance, a dental clinic, a pharmacy, an osteopath, an acupuncture clinic, an Anma massage clinic, a physical therapy clinic, an occupational therapy clinic, etc., or a care provider that can use care insurance, a physical therapy clinic,
  • the present invention relates to a system for claiming insurance payments used by occupational therapy clinics.
  • Receipt data is data representing the contents of an insurance payment request form (receipt).
  • “receipt” refers to a payment request application for requesting payment of medical fees, care fees, and medical expenses.
  • 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)).
  • Payment Fund Social Insurance Medical Fee Payment Fund
  • medical expenses may be submitted directly to the insurer.
  • medical fees are determined for each medical practice such as diagnosis, surgical procedure, medication, and testing for the insured patient.
  • 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 content of the Osteopathic Hospital, Acupuncture Clinic, Anma massage Hospital, etc., and during the treatment period during which these treatments are performed, the patient belongs using the created receipt according to the rules for claims for medical expenses Ask the insurer to pay for the medical expenses.
  • 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.
  • 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.
  • 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 payment request, examination and payment of a medical expenses application for a visit type judo reduction in a conventional general osteopathic clinic. As shown in FIG. 14, it is explained as a three-party model of patient A, osteopath B, and insurer D.
  • Patient A presents an insurance card at Osteopath B, and after the judo reduction teacher has completed an interview with Patient A at Osteopath B, a treatment plan is made.
  • a medical treatment payment application form is required when applying for medical treatment.
  • 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.
  • Osteopathic 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.
  • 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.
  • 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 settlement 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.
  • 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 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.
  • 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.
  • 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.
  • 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.
  • the insurance reimbursement processing or insurance factoring processing system 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.
  • 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.
  • 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.
  • 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. This can be said to be a preferable process in terms of operation.
  • 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.
  • 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,
  • a replacement or factoring upper limit rate setting means is used for the replacement or factoring upper limit rate
  • 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.
  • 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.
  • the “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.
  • 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.
  • the processing in the receipt creation application is not easy, and depending on the application, the accuracy of receipt (unsuccessful) is different 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 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
  • the replacement or factoring desired amount input means accepts the provisional input of the replacement or factoring desired amount from the insurance claimant terminal.
  • 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.
  • 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 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.
  • FIG. 1 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.
  • 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.
  • 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.
  • FIG. 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
  • 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
  • the phrase “advanced or factoring” may be abbreviated as “advanced / factoring”.
  • 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.
  • medical institutions that can use medical insurance, dental clinics, pharmacies, osteopaths, physical therapy clinics, occupational therapy clinics, and the like.
  • nursing care providers for nursing care providers, physical therapy clinics, occupational therapy clinics, etc. where care insurance is available.
  • the system is an extended system, particularly for replacement or factoring processing.
  • 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.
  • 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.
  • 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
  • a financial system 500 used by a financial institution. It is shown.
  • Insurance claimant terminal 200 includes a receipt creation application 210.
  • description is abbreviate
  • 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.
  • the insurance claimant terminal 200 Prior to the description of the insurance replacement processing 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.
  • 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 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 for creating receipt data from the treatment contents input via the input device.
  • 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.
  • 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.
  • proxy application data that is required to apply for medical expenses.
  • the insurance information database 230 includes basic information on local governments and other companies (information on insured persons, etc.), basic information on medical institutions such as hospitals and dispensing pharmacies (information on approval applications, etc.), and the Ministry of Health and Welfare when the law is revised. 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 claims. It is also preferable to store deposit / withdrawal data of an account in a financial institution.
  • the screening terminal 300 is a terminal that is used by a screening organization that receives a request from an insurer and receives a screening for 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 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 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.
  • the receipt data input means 110 includes an insurance claim amount input means 111
  • 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.
  • 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.
  • 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.
  • a receipt process that is, an insurance payment request process is executed.
  • 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.
  • 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.
  • 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.
  • 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 claim 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.
  • 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.
  • 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.
  • a replacement or factoring upper limit rate may be set for each insurance claimant.
  • 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.
  • 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.
  • the replacement 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.
  • 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 for simulating the execution result of the advance or factoring process applied to the insurance claimant for the desired amount of advance or factoring.
  • 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 payment 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 part or all of the reward or nursing 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.
  • the insurance reimbursement processing or insurance factoring processing system 100 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.
  • 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.
  • 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.
  • 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).
  • 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).
  • 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).
  • 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).
  • 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.
  • the advance or factoring fee rate setting means 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.
  • 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.
  • 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.
  • the reimbursement or factoring fee rate is shown numerically.
  • 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).
  • 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.
  • 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 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 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 total amount received is 950,000 yen, but 450,000 yen can be obtained early.
  • 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.
  • 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).
  • 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).
  • 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.
  • 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.
  • a transaction ID number is issued and notified to the insurance payer terminal 200.
  • 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.
  • 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 .
  • 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.
  • the replacement or factoring It also includes allowing the desired change and performing a turnover or factoring process.
  • 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.
  • 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.
  • 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.
  • 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.
  • the change or factoring usage rate is entered and determined on the input screen for the desired change or factoring amount. be able to.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • the receipt creation application 210a transmits not only the created receipt data but also the calculated examination pass expectation rate to the receipt data input means 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • 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.
  • the insurance reimbursement processing or insurance factoring processing system according to the present invention can be used as an ASP via a network.
  • 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.

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Abstract

L'invention concerne un système pour processus d'avance d'assurance ou un processus d'affacturage d'assurance, intervenant entre un patient, une clinique orthopédique, un assureur et une organisation de financement, et réalisant un processus d'intermédiation pour un processus de réception, et effectuant une avance ou un affacturage de tout ou partie d'un montant de demande de paiement d'assurance. Le système pour processus d'affacturage d'assurance comporte: un moyen 111 d'entrée de montant de demande de paiement d'assurance servant à recevoir une saisie d'un montant de demande de paiement d'assurance d'après des données de reçus liées à une demande de paiement d'assurance provenant d'un terminal de demandeur de paiement d'assurance; un moyen 122 d'entrée de montant souhaité d'avance ou d'affacturage servant à recevoir une saisie d'un montant souhaité d'avance ou d'affacturage par rapport au montant de demande de paiement d'assurance; un moyen 123 de spécification de taux limite supérieur d'avance ou d'affacturage servant à spécifier un taux limite supérieur d'avance ou d'affacturage pour chaque demandeur de paiement d'assurance ou pour chaque transaction d'un processus d'avance ou d'affacturage; et un moyen 126 de détermination de possibilité d'avance ou d'affacturage servant à autoriser l'exécution de l'avance ou de l'affacturage dans le cas où le montant souhaité d'avance ou d'affacturage est inférieur ou égal à un montant obtenu en multipliant le montant de demande de paiement d'assurance par le taux limite supérieur d'avance ou d'affacturage.
PCT/JP2017/013715 2017-03-31 2017-03-31 Système pour processus d'avance d'assurance ou processus d'affacturage d'assurance WO2018179375A1 (fr)

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JP2017535106A JP6313529B1 (ja) 2017-03-31 2017-03-31 保険立替処理または保険ファクタリング処理システム

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JP7413487B2 (ja) * 2022-02-28 2024-01-15 Ｇｍｏクリエイターズネットワーク株式会社 情報処理方法、プログラム及び情報処理装置

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JP7490474B2 (ja) 2020-07-08 2024-05-27 Tis株式会社 プログラム、支払管理装置、端末、残高管理装置、支払管理システム

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