WO2019100601A1 - Procédé et dispositif d'évaluation du risque de demandes d'indemnisation - Google Patents

Procédé et dispositif d'évaluation du risque de demandes d'indemnisation Download PDF

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WO2019100601A1
WO2019100601A1 PCT/CN2018/075677 CN2018075677W WO2019100601A1 WO 2019100601 A1 WO2019100601 A1 WO 2019100601A1 CN 2018075677 W CN2018075677 W CN 2018075677W WO 2019100601 A1 WO2019100601 A1 WO 2019100601A1
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type
preset
evaluation
parameter
logical
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PCT/CN2018/075677
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Chinese (zh)
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蔡宁
和婷
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平安科技（深圳）有限公司
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    • 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

Definitions

  • the present application relates to the field of data processing technologies, and in particular, to a method and an apparatus for evaluating risk claims.
  • the insurance industry's underwriting personnel need to approve the proofreading case in order to accurately make claims and reduce the risk of claims.
  • the insured personnel in the process of evaluating claims cases include the loss and the nuclear damage. After the damage is determined, the nuclear damage personnel will review the results of their work. If there is no doubt, they will agree to the result. If there is any objection, Will be returned to prevent fraud.
  • the present application provides a method and an apparatus for evaluating risk claims, and the main purpose thereof is to solve the problem that an existing nuclear damage personnel can easily miss some high-risk cases through manual review when conducting a review of a claim case. Bring some economic losses.
  • a method for evaluating risk claims including:
  • the parsing the logic information to be evaluated in the claim information and the historical policy information includes: extracting the claim information and the historical policy information, respectively, the number of times, the number of types, the type of the fee, and the type of the attribute Corresponding logical parameter; determining whether the value of the logical parameter corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute are respectively greater than a preset upper limit value, and/or less than a preset a lower limit value; if less than the preset upper limit value, and/or greater than the preset lower limit value, the logic corresponding to the number of times, the number of types, the type of the fee, and the attribute type
  • the parameter configures the number of intervals, and the number of intervals is used to distinguish parameters corresponding to the preset preset evaluation logic formula.
  • the matching according to the logic parameter and the preset evaluation logic, and counting the evaluation result of the claim case corresponding to the logic parameter includes: calculating the logic of the number of times according to the preset evaluation logic formula by using different interval numbers
  • the evaluation score corresponding to the parameter, and the preset evaluation logic formula is Where i is the number of intervals, x is the value of the logical parameter of the order type; and the evaluation score corresponding to the logical parameter of the number type is calculated according to the preset evaluation logic formula by different interval numbers, and the preset evaluation logic formula is Where i is the interval number, y is the value of the logical parameter of the number type; and the evaluation score corresponding to the logical parameter of the fee type is calculated according to the preset evaluation logic formula with different interval numbers, and the preset evaluation logic formula is Where i is the interval number, z is the value of the logical parameter of the expense type; and the evaluation score corresponding to the logical parameter of the attribute type is calculated according to the preset evaluation logic formula by different interval numbers, and the preset evaluation
  • the method further includes: generating an interval weight vector corresponding to the claim case according to the different claim product information, wherein the weight value corresponding to the fee type in the interval weight vector is respectively greater than the number of times, the number type, and the attribute type. Corresponding weights.
  • the method further includes: performing the evaluation result and the preset claim amount Comparing; if the comparison result is that the evaluation result is greater than two-thirds of the preset claim amount, the claim case is determined as a risk claim case, and the warning information is sent.
  • an apparatus for evaluating risk claims includes: an obtaining unit for acquiring claim information and historical policy information of an insured in a claim case; and an analyzing unit for parsing the claim information and the a logical parameter to be evaluated in the history policy information, wherein the logic parameter is used to reflect the situation in which the insured participates in the medical item in the claim case; the statistical unit is configured to match the preset evaluation logic according to the logic parameter, and The evaluation result of the claim case corresponding to the logical parameter is counted, and the preset evaluation logic is used to reflect the relationship between different logical parameters and different evaluation scores.
  • the parsing unit includes: an extracting module, configured to extract logical parameters corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute in the claim information and the historical policy information; the determining module is configured to: Determining whether the value of the logical parameter corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute are respectively greater than a preset upper limit value, and/or less than a preset lower limit value; a module, configured to determine, by the determining module, that the value of the logical parameter corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute are respectively less than a preset upper limit value, and/or greater than a preset
  • the lower limit value is the number of logical parameter configuration intervals corresponding to the number of times, the number of types, the type of the fee, and the attribute type, and the number of intervals is used to distinguish the corresponding preset evaluation logic formula Parameters.
  • the statistic unit includes: a calculation module, configured to calculate, according to the preset evaluation logic formula, an evaluation score corresponding to the logic parameter of the number of times in different interval numbers, where the preset evaluation logic formula is Where i is the number of intervals, x is the value of the logical parameter of the number of times; and the calculation module is further configured to calculate the evaluation score corresponding to the logical parameter of the number type according to the preset evaluation logic formula by using different interval numbers,
  • the preset evaluation logic formula is Where i is the interval number, y is the value of the logical parameter of the number type; and the calculation module is further configured to calculate the evaluation score corresponding to the logical parameter of the fee type by using different preset numbers according to the preset evaluation logic formula,
  • the preset evaluation logic formula is Where i is the number of intervals, z is the value of the logical parameter of the cost type; and the calculation module is further configured to calculate an evaluation score corresponding to the logical parameter of the attribute type by using different preset numbers according to the preset evaluation logic formula
  • the device further includes: a generating unit, configured to generate an interval weight vector corresponding to the claim case according to the different claim product information, wherein the weight value corresponding to the fee type in the interval weight vector is sequentially greater than the number of times, The weight corresponding to the type and attribute type.
  • a generating unit configured to generate an interval weight vector corresponding to the claim case according to the different claim product information, wherein the weight value corresponding to the fee type in the interval weight vector is sequentially greater than the number of times, The weight corresponding to the type and attribute type.
  • the apparatus further includes: a comparing unit, configured to compare the evaluation result with a preset claim amount; and a determining unit, configured to: if the comparison result is that the evaluation result is greater than three points of the preset claim amount Second, the claim case is determined as a risk claim case and an early warning message is sent.
  • a storage medium in which at least one executable instruction is stored, the executable instruction causing a processor to perform an operation corresponding to the evaluation method of the risk claim described above.
  • a server including: a processor, a memory, a communication interface, and a communication bus, wherein the processor, the memory, and the communication interface complete mutual communication through the communication bus
  • the memory is configured to store at least one executable instruction that causes the processor to perform an operation corresponding to the evaluation method of the risk claim described above.
  • the technical solution provided by the embodiment of the present application has at least the following advantages:
  • the present application provides a method and device for evaluating risk claims, first obtaining claim information and historical policy information of the insured in the claim case, and then parsing the claim information and the logical parameters to be evaluated in the historical policy information.
  • the logic parameter is used to reflect the situation in which the insured participates in the medical item in the claim case, and then matches the preset parameter according to the logical parameter, and collects the evaluation result of the claim case corresponding to the logical parameter, the pre-
  • the evaluation logic is used to reflect the relationship between different logical parameters and different evaluation scores. Compared with the existing nuclear damage personnel in the review of claim cases, all of them are manually reviewed, and it is easy to miss some high-risk cases.
  • the embodiment of the present application analyzes the claims related to the claims case.
  • FIG. 1 is a flowchart of a method for evaluating risk claims provided by an embodiment of the present application
  • FIG. 2 is a flowchart of another method for evaluating risk claims provided by an embodiment of the present application.
  • FIG. 3 is a block diagram of an apparatus for evaluating risk claims provided by an embodiment of the present application.
  • FIG. 4 is a block diagram of another apparatus for evaluating risk claims provided by an embodiment of the present application.
  • FIG. 5 is a schematic structural diagram of a server provided by an embodiment of the present application.
  • the embodiment of the present application provides a method for evaluating risk claims, as shown in FIG. 1 , the method includes:
  • the insured refers to a person who has the right to claim the insurance premium after the occurrence of the insured event according to the effective insurance contract
  • the claim case is a case arising from the insured person's insured item specified in the insured product.
  • the claim information includes all information generated by the insured in the claim case, such as the time when the insured product is accident insurance, the time of the accident, the cause of the accident, and a series of treatment information produced at the designated hospital after the accident occurred.
  • the information in the present application is not specifically limited.
  • the historical policy information is all information generated by the insured from the initiating time to the current time period regarding the insured product, such as the insured product, the standard premium of the insured product, the effective time of the insured, the expiration time, and the underwriting
  • the time and the application time if there is a claim case, the claim amount of the claim case, the cause of the claim case, and the like, the embodiment of the present application does not specifically limit.
  • the insured when the customer is insured, the insured is the person who delivers the premium.
  • the insured and the insured may be the same person, or may not be the same person. One insured may insure multiple people, that is, when the customer is insured.
  • An insured customer generates a policy corresponding to a policy number, in which the policy includes information for the insured to insure all insured persons, and each insured generates a sub-order corresponding to a sub-order number, for the embodiment of the present application
  • the policy information of the insured may be a separate policy information, or may be a sub-single information corresponding to the insured, which is not specifically limited in this embodiment.
  • the claim information will be saved, and finally the historical policy information will be obtained, and since each insured person corresponds to a policy number, the history policy information can be obtained through the policy number.
  • the logic parameter is used to reflect the situation in which the insured participates in the medical item in the claim case, because the meaning of the insurance company exists is to make risk claims for the customer, especially for the health insurance product, after the customer has a claim case, Generally, it is necessary to treat certain medical items, and the insurance company will pay for the expenses incurred by these medical items. However, the production of a large number of medical items may not be within the scope of claims for insurance products, and it is necessary to claim claims. And the policy information is evaluated by the insured in the medical project.
  • the logical parameter may include information such as the time, the number of times, the content, the fee, and the like of the insured person participating in the medical project, such as one month (this time + history all cases)
  • the number of visits to the same disease within one state one visit: the same hospital on the same day
  • the number of hospitals visited within one month this state + all cases of history
  • the number of hospital visits within one month this + history of all cases
  • the time of the second outbreak is abnormal (from the time when my policy is effective), the time of this insurance Abnormal (from the end of my policy), this treatment is an overseas clinic (hospital property), the time of this outpatient visit, the history of all cases, the rules of mutual exclusion rules (the insured), physical therapy (cost type) fees ( With the hospital) public, physical therapy (cost type) costs (with the hospital) private, Chinese medicine treatment costs, Chinese medicine treatment times (number of visits: the same hospital on the same day), Chinese herbal medicine single cost, hospitalization expenses, inspection and inspection fees accounted for the total cost Proportion, whether to use medical insurance card
  • the corresponding logical parameters may be extracted through the storage identifiers of the various parameters in the claim information and the historical policy information, and then parsed. Specific data corresponding to these parameters, such as the amount of public outpatient applications (high-end) is 5,000 yuan.
  • the preset evaluation logic is configured to reflect a relationship between different logical parameters and different evaluation scores, wherein the evaluation score is a score for evaluating each logical parameter.
  • the data of each logical parameter may be divided into scores.
  • the logical parameter in order to determine the score according to the content of each range, for example, the logical parameter is the number of visits to the same disease within one month (this time + all cases of history) (one visit: the same hospital on the same day), the logical parameters parsed corresponding The data is 3 times, and the corresponding logical parameters have a score range of 2 points for 2 times, 3 points for 2 or 3 times, 4 points for 4 times, and 5 points for 5 times or more. The higher the score, the higher the risk of the claims case.
  • the logical parameters include not only the parameters of the order type but also the parameters of the number, cost, attribute, etc., the data of the logical parameters of each type corresponds to the range of division.
  • the evaluation results need to be counted according to the scores of all logical parameters, so that the staff can use the evaluation results to determine whether the current claim case is a dangerous claim case.
  • the scores obtained by each logical parameter need to be counted, and the average value can be calculated for the summation, and then the average value is judged whether the average value exceeds a specific risk value, and if it is exceeded, it is determined as a risk claim case, and is performed to the technician.
  • Early warning is the average value is judged whether the average value exceeds a specific risk value, and if it is exceeded, it is determined as a risk claim case, and is performed to the technician.
  • the application provides a method for evaluating risk claims, and the existing nuclear damage personnel are manually audited, and it is easy to miss some high-risk cases.
  • the embodiment of the present application passes the claims according to the claims.
  • the information and historical policy information analyzes the logical parameters related to the claim case, matches the logical parameters with the preset evaluation logic, obtains the evaluation result, and realizes the computer automatically calculates the evaluation result without manual operation, ensuring that each claim case is in accordance with a standard. Conduct an assessment to improve the efficiency of claims assessments.
  • the embodiment of the present application provides another method for evaluating risk claims, as shown in FIG. 2, the method includes:
  • step 201 Obtain the claim information and historical policy information of the insured in the claim case. This step is the same as the method of step 102 shown in FIG. 1, and details are not described herein again.
  • the number of types can include the number of visits to the same disease within one month (this time + all cases of history) (one visit: the same hospital on the same day), the number of Chinese medicine treatments (number of visits: same hospital on the same day), historical case E ( WeChat, APP) number of claims application, the number of types is less than one month (this + history of all cases) the number of hospitals, within one month (this + history of all cases) the number of treatments, this time out of the abnormal time ( The time from the effective date of my policy), the abnormal time of this insurance (from the end of my policy), the number of hospital stays (single), the underwriting option is MHD and the number of first-time insurance policies, the underwriting option is non-MHD policy and the first of the policy
  • the cost type is physical therapy (cost type) fee (with hospital) public, physical therapy (cost type) fee (with hospital) private, Chinese medicine treatment fee, Chinese herbal medicine single fee, historical case E-based claim application amount ( Accumulated), public outpatient application amount
  • the preset upper limit value and/or the lower limit value are preset values of the technician according to different types of logic parameters, for example, the number of types of logic parameters is within one month (this time + history all case states)
  • the preset upper limit of the number of hospitals to be treated is 8. When the number of hospitals in the insured's claims information is 10 in one month, it is greater than the preset upper limit. For the insured's hospital The data is obviously unreasonable and requires early warning to the underwriters who handle the claims.
  • the logical parameter configuration corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute respectively The number of intervals.
  • the interval number is used to distinguish parameters corresponding to the preset preset evaluation logic formula. Since different types of logic parameters use the preset evaluation logic formula to evaluate the score, the data corresponding to each logical parameter needs to be replaced by a formula that can be matched. The calculated value, therefore, it is necessary to divide the number of intervals for each logical parameter.
  • the logical parameters of the number type, the number type, and the cost type can be divided into five interval numbers, wherein the number of times and the number type are insured.
  • the importance of judging the risk of claim in the claim case is the second most important.
  • the number of times and the number of each type are 1, 2, 3, 4, and 5.
  • the importance of determining the risk of claim in the insurance claim case is The most important, the cost type is 6, 7, 8, 9, and 10, respectively. It is not important to determine the importance of the claim risk in the insurance claim case for the attribute type, and the number of each type of the attribute type is 0.
  • the attribute type logic parameter is whether to use the medical insurance card (social security bill), the data is "yes and no", for "yes”
  • the number of intervals is 0, and the number of intervals for "No” is 2; the number of logical parameters of this type is abnormal for this time (from the time when the policy is effective), and the data are "more than 7 months, 5-6 months, Within 3-4 months, 1-2 months, and 1 month, the number of intervals of "more than 7 months” is 1, and so on.
  • the cost type logic parameter is the cost of traditional Chinese medicine treatment.
  • the data are respectively 0-300. 300-500, 500-700, 700-900, 900 or more", "0-300,” the interval number is divided into 6, and so on, and the embodiment of the present application is not specifically limited.
  • the logical parameters of different data are converted into parameters that can be replaced in the preset evaluation logic formula for formula operations.
  • the current risk claim evaluation method can be embedded into any insurance management system in the form of a calculation module to connect with the database storing the insurance customer information, and obtain data for calculation.
  • the number of intervals that need to be configured in the current step 204 may be pre-configured in the system cache.
  • the number of intervals of the logical parameter is determined according to the specific data of the logical parameter, and the specific program is compiled.
  • the embodiment is not specifically limited.
  • the logic parameter is reported to the display interface, and is not used as a parameter in the preset evaluation logic formula. Operation.
  • the preset evaluation logic formula calculates, according to the preset evaluation logic formula, an evaluation score corresponding to the logical parameter of the number of times in different interval numbers.
  • the preset evaluation logic formula is Where i is the number of intervals and x is the value of the logical parameter of the number type.
  • the logical parameter is the public hospitalization application amount (high end), and the cost of the customer 1 found in the database in the claim event and the historical policy information is 25,000 yuan, and the current logical parameter is determined according to the number of intervals corresponding to the type of the fee type.
  • the number of intervals is 8, and 25000 and 8 are brought into the preset evaluation logic formula to obtain an evaluation score of about 76.
  • the preset evaluation logic formula is stored in the calculation module in the form of program code, and when the calculation program is started, the operation is directly performed according to each logic parameter, and the evaluation scores of all the logic parameters are obtained.
  • the evaluation score corresponding to the logical parameter of the number type is calculated by different interval numbers according to the preset evaluation logic formula 205b along with the step 205a.
  • the preset evaluation logic formula is Where i is the number of intervals and y is the value of the logical parameter of the number type.
  • Step 205b is the same as the specific implementation method of step 205a, and will not be described again.
  • the evaluation score corresponding to the logical parameter of the fee type is calculated by different interval numbers according to the preset evaluation logic formula 205c along with the step 205a.
  • the preset evaluation logic formula is Where i is the interval number and z is the value of the logical parameter of the expense type.
  • Step 205c is the same as the specific implementation method of step 205a, and will not be described again.
  • the evaluation score corresponding to the logical parameter of the attribute type is calculated in different interval numbers according to the preset evaluation logic formula 205d along with the step 205a.
  • the preset evaluation logic formula is Where i is the number of intervals and l is the value of the logical parameter of the attribute type.
  • Step 205d is the same as the specific implementation method of step 205a, and will not be described again.
  • the estimation result of the evaluation score corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute is obtained according to a preset interval weight vector.
  • the weight corresponding to the interval number is the weight corresponding to the number of interval types, a3 is the weight corresponding to the number of interval types, and a4 is the weight corresponding to the interval number of the attribute type, wherein the underwriting can be based on the claim case
  • the personnel determine the accuracy of the evaluation results of different interval numbers in the evaluation.
  • A1 in the weight vector is determined as the column vector, that is, a a1 can be a column vector, including the weights corresponding to the five interval numbers.
  • the specific value of the weight is the same as the size of the interval number, that is, the evaluation score of each logical parameter needs to be multiplied by the same weight as the interval corresponding to each logical parameter to obtain an evaluation result. No specific restrictions.
  • the general preset interval weight vector may be determined by the underwriting personnel of the insurance company according to the historical claim risk data, which is not specifically limited in the embodiment of the present application.
  • the statistical method is to multiply the evaluation score corresponding to each logical parameter and the interval weight vector to obtain an evaluation result for comparison.
  • the embodiment of the present application further includes: generating an interval weight vector corresponding to the claim case according to the different claim product information, wherein the weight value corresponding to the fee type in the interval weight vector is sequentially greater than the number of times, The weight corresponding to the type and attribute type.
  • the order of weights is a1>a2>a3>a4.
  • different insurance products have different claims effects in claims cases, such as the large claims insurance claims risk is much larger than the small insurance corresponding claims risk.
  • the other information may be determined according to the information corresponding to the claim product in the claim case or the historical policy information to determine the interval in the risk-free claim case.
  • the weight vector is used as a reference to directly generate the corresponding interval weight vector.
  • the preset evaluation logic formula is used as a form data for converting all types of data into a certain range, so as to facilitate The insurance company compares the amount of claims most concerned in the claims case to determine whether it is a risk claim case.
  • the preset claim amount is the maximum amount that should be paid in different claims products, which is not specifically limited in the embodiment of the present application.
  • the claim case is determined as a risk claim case, and the warning information is sent.
  • the calculated evaluation result In order to make the calculated evaluation result accurately determine whether it is a risk claim case, if it is greater than two-thirds of the setting, it can be accurately determined as a risk claim case, and an early warning is issued to the underwriting personnel, so that the underwriter can proceed to the next step.
  • the audit is not more than two-thirds of the preset claim amount, the current claim case is a normal claim case and will not be reviewed, so as to reduce the steps of human handling, thereby improving the efficiency of risk claim case evaluation.
  • the present application provides another method for evaluating risk claims.
  • the embodiment of the present application analyzes the logical parameters related to the claim case according to the claim information and the historical policy information, and sets the number of intervals of the logical parameters as parameters of the preset evaluation logic formula. Perform calculations to obtain the evaluation scores of each logical parameter, calculate the evaluation results by weight calculation, and compare with the preset claims amount to determine whether it is a risk claim case, and realize the computer automatically calculate the evaluation result without human intervention, ensuring each
  • the claim cases are evaluated according to a standard, and the data of all the logical parameters are converted into the amount by the preset evaluation logic formula, thereby realizing the purpose of comparing the different values in the claim case into the form of the amount, thereby improving The efficiency of claims assessment.
  • the embodiment of the present application provides an apparatus for evaluating risk claims.
  • the apparatus includes: an obtaining unit 31, an analyzing unit 32, and a statistics unit 33.
  • the obtaining unit 31 is configured to obtain the claim information and the historical policy information of the insured in the claim case; the obtaining unit 31 is configured to perform the function module for obtaining the claim information and the historical policy information of the insured in the claim case for the risk claim evaluation device.
  • the parsing unit 32 is configured to parse the claim information and the logical parameter to be evaluated in the historical policy information, where the logic parameter is used to reflect the situation in which the insured participates in the medical item in the claim case; the parsing unit 32 is The risk claim evaluation device performs a function module that parses the claim information and the logical parameter to be evaluated in the history policy information.
  • the statistic unit 33 is configured to perform matching on the logical parameter according to the preset evaluation logic, and collect the evaluation result of the claim case corresponding to the logical parameter, where the preset evaluation logic is used to reflect different logical parameters and different evaluation scores. Relationship between.
  • the statistic unit 33 performs, for the risk claim evaluation device, a function module that matches the preset parameter according to the logic parameter, and counts the evaluation result of the claim case corresponding to the logic parameter.
  • the application provides a risk claim evaluation device, and the existing nuclear damage personnel in the review of the claims case are manually audited, and it is easy to miss some high-risk cases.
  • the information and historical policy information analyzes the logical parameters related to the claim case, matches the logical parameters with the preset evaluation logic, obtains the evaluation result, and realizes the computer automatically calculates the evaluation result without manual operation, ensuring that each claim case is in accordance with a standard. Conduct an assessment to improve the efficiency of claims assessments.
  • the embodiment of the present application provides another apparatus for evaluating risk claims.
  • the apparatus includes: an obtaining unit 41, an analyzing unit 42, and a statistics unit 43.
  • the obtaining unit 41 is configured to obtain claim information and historical policy information of the insured in the claim case;
  • the parsing unit 42 is configured to parse the claim information and the logical parameter to be evaluated in the historical policy information, where the logical parameter is used In response to the situation in which the insured participates in the medical item in the claim case;
  • the statistical unit 43 is configured to match the preset parameter according to the logical parameter, and collect the evaluation result of the claim case corresponding to the logical parameter, Pre-set evaluation logic is used to reflect the relationship between different logic parameters and different evaluation scores.
  • the parsing unit 42 includes: an extracting module 4201, configured to extract logical parameters corresponding to the order type, the number type, the fee type, and the attribute type in the claim information and the historical policy information; the determining module 4202 And determining whether the value of the logical parameter corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute are respectively greater than a preset upper limit value, and/or less than a preset lower limit.
  • a configuration module 4203 configured to determine, by the determining module 4202, that the value of the logical parameter corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute are respectively less than a preset upper limit value, and And if the value is greater than the preset lower limit value, the number of the logical parameter corresponding to the number of times, the number of types, the type of the fee, and the type of the attribute are respectively configured, and the number of the interval is used to distinguish the replacement Set the parameters corresponding to the evaluation logic formula.
  • the statistic unit 43 includes: a calculation module 4301, configured to calculate, according to the preset evaluation logic formula, an evaluation score corresponding to the logical parameter of the number of times in different interval numbers, where the preset evaluation logic formula is Where i is the number of intervals, x is the value of the logical parameter of the number of times; and the calculating module 4301 is further configured to calculate the evaluation score corresponding to the logical parameter of the number type according to the preset evaluation logic formula by using different number of intervals, The preset evaluation logic formula is Where i is the number of intervals, y is the value of the logical parameter of the number type; and the calculating module 4301 is further configured to calculate the evaluation score corresponding to the logical parameter of the fee type by using different preset numbers according to the preset evaluation logic formula.
  • the preset evaluation logic formula is Where i is the number of intervals, z is the value of the logical parameter of the cost type; and the calculation module 4301 is further configured to calculate the evaluation score corresponding to the logical parameter of the attribute type by using the preset evaluation logic formula in different interval numbers,
  • the preset evaluation logic formula is Where i is the number of intervals, l is the value of the logical parameter of the attribute type, and the statistic module 4302 is configured to statistically obtain the type of the number, the type of the number, the type of the fee, and the location according to a preset interval weight vector. The evaluation result of the evaluation score corresponding to the attribute type.
  • the device further includes: a generating unit 44, configured to generate an interval weight vector corresponding to the claim case according to different claims product information, where the weight corresponding to the fee type in the interval weight vector is sequentially greater than the number of times, The weight of the number type and attribute type.
  • a generating unit 44 configured to generate an interval weight vector corresponding to the claim case according to different claims product information, where the weight corresponding to the fee type in the interval weight vector is sequentially greater than the number of times, The weight of the number type and attribute type.
  • the device further includes: a comparing unit 45, configured to compare the evaluation result with a preset claim amount; and a determining unit 46, configured to: if the comparison result is that the evaluation result is greater than the preset claim amount Two-thirds of the cases are identified as risk claims cases and sent early warning information.
  • the present application provides another risk claim evaluation device.
  • the embodiment of the present application analyzes the logical parameters related to the claim case according to the claim information and the historical policy information, and sets the logical parameter configuration interval number as the parameter of the preset evaluation logic formula. Perform calculations to obtain the evaluation scores of each logical parameter, calculate the evaluation results by weight calculation, and compare with the preset claims amount to determine whether it is a risk claim case, and realize the computer automatically calculate the evaluation result without human intervention, ensuring each The claim cases are evaluated according to a standard, and the data of all the logical parameters are converted into the amount by the preset evaluation logic formula, thereby realizing the purpose of comparing the different values in the claim case into the form of the amount, thereby improving The efficiency of claims assessment.
  • the embodiment of the present application further provides a computer readable storage medium, where the computer program is stored, and when the program is executed by the processor, the following steps are implemented: obtaining a claim case Claim information and historical policy information of the insurer; parsing the logic information to be evaluated in the claim information and the historical policy information, wherein the logic parameter is used to reflect the situation in which the insured participates in the medical item in the claim case; The logical parameters are matched with the preset evaluation logic, and the evaluation result of the claim case corresponding to the logical parameter is used, and the preset evaluation logic is used to reflect the relationship between different logical parameters and different evaluation scores.
  • the server may include a processor 51, a communications interface 52, a memory 53, and a communication bus 54.
  • the processor 51, the communication interface 52, and the memory 53 complete communication with each other via the communication bus 54.
  • the communication interface 54 is configured to communicate with network elements of other devices such as clients or other servers.
  • the processor 51 is configured to execute a program, and specifically may perform related steps in the testing method embodiment of the application.
  • the program can include program code, the program code including computer operating instructions.
  • the processor 51 may be a central processing unit CPU, or an Application Specific Integrated Circuit (ASIC), or one or more integrated circuits configured to implement the embodiments of the present application.
  • ASIC Application Specific Integrated Circuit
  • the one or more processors included in the terminal may be the same type of processor, such as one or more CPUs; or may be different types of processors, such as one or more CPUs and one or more ASICs.
  • the memory 53 is configured to store a program.
  • the memory 53 may include a high speed RAM memory and may also include a non-volatile memory such as at least one disk memory.
  • the program may be specifically configured to enable the processor 51 to: obtain the claim information and the history policy information of the insured in the claim case; and parse the claim information and the logical parameter to be evaluated in the historical policy information, the logic parameter
  • the method for responding to the insured person participating in the medical item in the claim case; matching the preset parameter according to the logic parameter, and counting the evaluation result of the claim case corresponding to the logic parameter, where the preset evaluation logic is used The relationship between different logical parameters and different evaluation scores.
  • modules in the devices of the embodiments can be adaptively changed and placed in one or more devices different from the embodiment.
  • the modules or units or components of the embodiments may be combined into one module or unit or component, and further they may be divided into a plurality of sub-modules or sub-units or sub-components.
  • any combination of the features disclosed in the specification, including the accompanying claims, the abstract and the drawings, and any methods so disclosed, or All processes or units of the device are combined.
  • Each feature disclosed in this specification (including the accompanying claims, the abstract and the drawings) may be replaced by alternative features that provide the same, equivalent or similar purpose.
  • the various component embodiments of the present application can be implemented in hardware, or in a software module running on one or more processors, or in a combination thereof.
  • a microprocessor or digital signal processor may be used in practice to implement some or all of the functionality of some or all of the components of the risk claim evaluation method and apparatus in accordance with embodiments of the present application.
  • the application can also be implemented as a device or device program (e.g., a computer program and a computer program product) for performing some or all of the methods described herein.
  • Such a program implementing the present application may be stored on a computer readable medium or may be in the form of one or more signals. Such signals may be downloaded from an Internet website, provided on a carrier signal, or provided in any other form.

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Abstract

La présente invention concerne un procédé et un dispositif d'évaluation du risque de demandes d'indemnisation, se rapportant au domaine technique du traitement de données, visant principalement à résoudre le problème dû au fait que des dossiers à haut risque qui échappent à un examen manuel pendant l'examen de demandes d'indemnisation engendrent des pertes économiques pour une compagnie d'assurance. Le procédé d'évaluation du risque de demandes d'indemnisation comporte les étapes consistant à: obtenir des informations de demande d'indemnisation et des informations historiques de police d'assurance d'un assuré dans un dossier de demande d'indemnisation (101); analyser des paramètres logiques à évaluer dans les informations de demande d'indemnisation et les informations historiques de police d'assurance (102), les paramètres logiques reflétant une situation où l'assuré est impliqué dans un programme de traitement médical au cours d'un dossier de demande d'indemnisation; et confronter les paramètres logiques à une logique d'évaluation préconfigurée, et recueillir des statistiques sur un résultat d'évaluation du dossier de demande d'indemnisation correspondant aux paramètres logiques (103), la logique d'évaluation préconfigurée reflétant une relation entre différents paramètres logiques et différents scores d'évaluation. Le procédé de l'invention est utilisé pour évaluer des demandes d'indemnisation à haut risque.
PCT/CN2018/075677 2017-11-22 2018-02-07 Procédé et dispositif d'évaluation du risque de demandes d'indemnisation WO2019100601A1 (fr)

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