WO2020119116A1 - 基于数据分析的医保审核方法、装置、设备和存储介质 - Google Patents

基于数据分析的医保审核方法、装置、设备和存储介质 Download PDF

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Publication number
WO2020119116A1
WO2020119116A1 PCT/CN2019/096012 CN2019096012W WO2020119116A1 WO 2020119116 A1 WO2020119116 A1 WO 2020119116A1 CN 2019096012 W CN2019096012 W CN 2019096012W WO 2020119116 A1 WO2020119116 A1 WO 2020119116A1
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information
medical insurance
medicine
related information
special medicine
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PCT/CN2019/096012
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English (en)
French (fr)
Inventor
李云峰
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平安医疗健康管理股份有限公司
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Publication of WO2020119116A1 publication Critical patent/WO2020119116A1/zh

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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
    • G06Q10/00—Administration; Management
    • G06Q10/10—Office automation; Time management
    • G06Q10/103—Workflow collaboration or project management
    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06F—ELECTRIC DIGITAL DATA PROCESSING
    • G06F18/00—Pattern recognition
    • G06F18/20—Analysing
    • G06F18/24—Classification techniques
    • G06F18/241—Classification techniques relating to the classification model, e.g. parametric or non-parametric approaches
    • G06F18/2411—Classification techniques relating to the classification model, e.g. parametric or non-parametric approaches based on the proximity to a decision surface, e.g. support vector machines
    • 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
    • G06V—IMAGE OR VIDEO RECOGNITION OR UNDERSTANDING
    • G06V10/00—Arrangements for image or video recognition or understanding
    • G06V10/20—Image preprocessing
    • G06V10/22—Image preprocessing by selection of a specific region containing or referencing a pattern; Locating or processing of specific regions to guide the detection or recognition

Definitions

  • This application relates to the field of medical insurance management, in particular to medical insurance audit methods, devices, equipment and storage media based on data analysis.
  • the function of the current medical insurance audit platform is too simple to deal with all kinds of special problems in the actual audit process. That is, the current audit platform usually conducts audits on the authenticity and reimbursement scope of medical insurance materials; such medical insurance audits are not comprehensive and are prone to problems of medical insurance document audit errors. How to comprehensively and accurately medical insurance audits has become an urgent problem to be solved. technical problem.
  • the main purpose of this application is to provide medical insurance audit methods, devices, equipment and storage media based on data analysis, aiming to achieve a comprehensive and accurate medical insurance claims audit.
  • the present application provides a medical insurance audit method based on data analysis, which includes the following steps:
  • the present application also provides a medical insurance audit device based on data analysis.
  • the medical insurance audit device based on data analysis includes:
  • Receiving audit module used to receive medical insurance claims review request and obtain claim materials to be reviewed
  • the analysis and judgment module is used to analyze the claim materials to obtain claim-related information, and determine whether the medical insurance claims include special medicine claims according to the claims-related information;
  • the medicine judgment module is used to judge whether the special medicine complies with the medication rules if the medical insurance claims include special medicine claims;
  • the audit output module is used to output the medical insurance claims review if the special medicine meets the medication rules.
  • this application also provides a medical insurance auditing device based on data analysis
  • the medical insurance auditing device based on data analysis includes: a memory, a processor, and computer-readable instructions stored on the memory and executable on the processor, wherein:
  • the computer-readable instructions When executed by the processor, the computer-readable instructions implement the steps of the medical insurance audit method based on data analysis as described above.
  • this application also provides a computer storage medium
  • Computer-readable instructions are stored on the computer storage medium. When the computer-readable instructions are executed by the processor, the steps of the medical insurance audit method based on data analysis as described above are implemented.
  • the terminal receives a review request for medical insurance claims and obtains claim materials to be reviewed; analyzes the claim materials to obtain claims-related information.
  • the relevant information about the claims determines whether the medical insurance claims include special medicine claims; if the medical insurance claims include special medicine claims, it is determined whether the special drugs meet the medication rules; if the special drugs meet the medication rules, the medical insurance is output
  • the claim review is passed. In this application, the medical insurance claims are analyzed against the claim materials to obtain claim-related information.
  • the terminal obtains the claim-related information (type of disease, medication information, hospitalization information, etc.) in the claim-related information according to the claim-related information ), claims amount and other information, to determine whether the medical insurance claims include special drug claims, if the medical insurance claims include special drug claims, then determine whether the special drugs comply with the rules of medication, this application for medical insurance review detailed review to Special medicines comply with the medication rules, and realize comprehensive and accurate medical insurance claims review for medical insurance drugs.
  • the claim-related information type of disease, medication information, hospitalization information, etc.
  • FIG. 1 is a schematic structural diagram of a device for a hardware operating environment involved in an embodiment of the present application
  • FIG. 2 is a schematic flowchart of a first embodiment of a medical insurance review method based on data analysis of the application;
  • FIG. 3 is a schematic diagram of functional modules of an embodiment of a medical insurance audit device based on data analysis of the present application.
  • the present application provides a solution to obtain claims-related information by analyzing medical insurance materials, and the terminal determines whether the medical insurance claims include special medicine claims based on the claims-related information; if the medical insurance claims include special medicine claims, then Determine whether the special medicine complies with the medication rules; if the special medicine complies with the medication rules, the medical insurance claims review will be passed.
  • This application is based on data analysis to achieve a comprehensive and accurate medical insurance review.
  • FIG. 1 is a terminal of a hardware operating environment involved in a solution of an embodiment of the present application (also called a medical analysis audit device based on data analysis, where the medical analysis audit device based on data analysis may be a separate data analysis-based
  • the structure of the medical insurance auditing device may also be a combination of other devices and a medical insurance auditing device based on data analysis.
  • the terminal may be a fixed terminal or a mobile terminal.
  • the terminal may include: a processor 1001, for example, a central processor Central Processing Unit, CPU), network interface 1004, user interface 1003, memory 1005, communication bus 1002.
  • the communication bus 1002 is used to implement connection communication between these components.
  • the user interface 1003 may include a display (Display), an input unit such as a keyboard (Keyboard), and the optional user interface 1003 may also include a standard wired interface and a wireless interface.
  • the network interface 1004 may optionally include a standard wired interface and a wireless interface (such as wireless fidelity WIreless-FIdelity, WIFI interface).
  • the memory 1005 may be a high-speed RAM memory or a stable memory (non-volatile memory), for example, disk storage.
  • the memory 1005 may optionally be a storage device independent of the foregoing processor 1001.
  • terminal structure shown in FIG. 1 does not constitute a limitation on the terminal, and may include more or fewer components than those illustrated, or combine certain components, or arrange different components.
  • the computer software product is stored in a storage medium (storage medium: also called computer storage medium, computer medium, readable medium, readable storage medium, computer readable storage medium, or directly called medium, etc., which can be Non-volatile readable storage media, such as RAM, magnetic disks, and optical disks, include several instructions to enable a terminal device to perform the method described in each embodiment of the present application, in a memory 1005 as a computer storage medium It may include an operating system, a network communication module, a user interface module, and computer readable instructions.
  • the network interface 1004 is mainly used to connect to the back-end server and perform data communication with the back-end server;
  • the user interface 1003 is mainly used to connect to the client (user end) and perform data communication with the client;
  • the processor 1001 can be used to call computer-readable instructions stored in the memory 1005 and execute the steps in the medical insurance audit method based on data analysis provided by the following embodiments of the present application.
  • the medical insurance audit method based on data analysis includes:
  • the terminal receives the medical insurance claim review request, and correspondingly displays the material input page for the user Enter the claim materials, the terminal obtains the claim materials entered by the user, and reviews the claim materials to determine whether the medical insurance claims applied by the user meet the claim standards, specifically:
  • the medical insurance audit method based on data analysis includes:
  • Step S10 Receive a medical insurance claim review request and obtain claim materials to be reviewed.
  • the terminal receives the medical insurance claim review request, among which, the medical insurance claim review request is triggered in various ways, which are not limited in this embodiment, for example, the user triggers the medical insurance claim review request on the interface of a designated application software in the terminal, or The user verbal command triggers the medical insurance claims review request.
  • the terminal displays the prompt message for uploading medical insurance claim materials.
  • the user uploads the medical insurance related claim materials on the medical insurance claim interface according to the prompt information.
  • the terminal obtains The claim material uploaded by the user is regarded as the claim material to be reviewed.
  • the claim materials include: 1. The original insurance contract; 2. The original ID of the insured; 3. Fill in the claim application information, including: claim application, authorization letter (if agent), entrust bank transfer Application form; 4. Original invoices for treatment expenses incurred by the insured during outpatient or inpatient hospitals and the corresponding list of receipts; 5. Diagnosis and treatment records of designated hospitals (such as original outpatient medical records and copies of inpatient medical records after hospitalization, summary of discharge , Diagnosis certificate, various inspection reports, etc.); 6. Death or disability due to accident or disease, accident certificate, death certificate, and identification certificate of the designated disability appraisal agency, etc.
  • the terminal screening rules are preset, where the preset screening rules can be set according to specific scenarios, for example, the preset screening rules include clarity rules, and the terminal performs the pre-screening rules on electronic materials uploaded by users Initial screening, and use electronic materials that meet the preset screening rules as claim materials to be reviewed for review of claim materials, specifically:
  • Step a Receive an audit request for medical insurance claims, and output material upload prompt information to prompt the user to upload the electronic file corresponding to medical insurance claims;
  • Step b Receive the electronic document uploaded by the user, and determine whether the electronic document meets the preset screening rules
  • Step c if the electronic document does not meet the preset screening rule, output prompt information to prompt the user to upload again;
  • Step d If the electronic document meets the preset screening rule, use the electronic document as the claim material to be reviewed.
  • the terminal receives the review request for medical insurance claims, and the terminal outputs material upload prompt information to prompt the user to upload the electronic document corresponding to the medical insurance claim;
  • the user uploads the relevant electronic document
  • the terminal receives the electronic document uploaded by the user, and the terminal according to the preset
  • the screening rule filters the electronic document uploaded by the user, that is, the terminal compares the attribute information of the electronic document with the preset screening rule to obtain a comparison result, and the terminal judges whether the electronic document meets the preset screening rule according to the comparison result ; If the electronic document does not meet the preset screening rule, for example, the format of the electronic document uploaded by the user does not meet the preset screening rule, the terminal outputs a prompt message to prompt the user to re-upload; if the electronic document If the preset screening rules are met, the electronic document is used as claim materials to be reviewed.
  • the terminal displays the medical insurance claims interface on the interface.
  • the user can upload electronic documents based on the medical insurance claims interface.
  • the terminal sets preset filtering rules to perform electronic file uploads by the user.
  • the principle of saving readable instructions is implemented in this embodiment, which effectively avoids the problem of an increase in the review cycle caused by the uploaded electronic document format not conforming to the regulations.
  • Step S20 Analyze the claims materials to obtain claims-related information, and determine whether the medical insurance claims include special medicine claims based on the claims-related information.
  • the terminal parses the claim materials to obtain claim-related information, where the claim-related information includes: user identification information (for example, user ID number), user disease information (for example, disease records on the medical record book), and user medical insurance information (for example , The user's medical insurance type, medical insurance policy information), user medication information (for example, user prescription information), etc.
  • user identification information for example, user ID number
  • user disease information for example, disease records on the medical record book
  • user medical insurance information for example , The user's medical insurance type, medical insurance policy information
  • user medication information for example, user prescription information
  • OCR Optical Character
  • Recognition Optical Character Recognition
  • OCR refers to electronic devices (such as scanners or digital cameras) check the characters printed on paper, determine the shape by detecting dark and bright patterns, and then use character recognition Method The process of translating shapes into computer text; specifically: 1. First detect and extract the text area (Text region); 2. Then use radon Hough transform and other methods for text correction; 3. Split the picture of a single line of text by projecting the histogram; 4. Finally, perform character recognition on the picture of the text, for example, based on the projection histogram extreme point as a candidate segmentation point and use the preset The character classifier searches for the best segmentation point.
  • the character recognition preset character classifier is used for a single character. That is, adjust grayscale-binarization-correct image-extract feature information-preset character classifier (preset character classifier has decision tree, neural network, etc. ).
  • the OCR recognition technology is used to process the claim materials, and the related information about claims can be obtained automatically without manual review.
  • the terminal judges whether to include claims for special medicines based on the obtained claims-related information; among them, special medicines refer to the treatment of certain special diseases, and the price of special medicines is usually higher; this implementation
  • the example shows a specific implementation method for determining whether the medical insurance claims include special medicine claims based on the claims-related information:
  • the terminal obtains the medicine-related information in the claims-related information
  • the terminal obtains the medicine-identification information in the medicine-related information
  • the terminal compares the medicine identification information with the identification information of each special medicine in the preset special medicine identification set, where,
  • the preset special medicine identification set refers to a set of special medicine identification information set in advance; if there is a special medicine identification matching the medicine identification information in the preset special medicine identification set, whether the medical insurance claims include special medicine claims, and vice versa.
  • Step S30 if the medical insurance claims include special medicine claims, it is determined whether the special medicines comply with the medication rules.
  • the terminal needs to review the use of special medicines to determine whether the special medicines comply with the rules for use of medicines, so as to prevent wrong claims for special medicines.
  • the special medicine complies with the medication rules, which can be judged according to the drug usage rules of the special medicine, mainly around several aspects: 1. Whether the special medicine is symptomatic; 2. The dosage of the special medicine Whether it meets the standard; 3. Whether the medication time of the special medicine complies with the standard. If all of the above are met, the terminal can judge that the special medicine complies with the medication rules.
  • the drug use rules for special drugs are reviewed, and the use standard information of the special drugs is taken into consideration, which makes the drug review of the special drugs more comprehensive and detailed, and avoids the situation that the special drugs are over-reimbursed.
  • Step S40 if the special medicine complies with the medication rules, it outputs medical insurance claims and passes the review.
  • the terminal determines that the special medicine complies with the medication rules, that is, the terminal determines that the medical insurance claims meet the rules, the terminal outputs the medical insurance claims review and passes. Further, after the terminal determines that the medical insurance review is passed, the terminal can issue medical insurance and improve the efficiency of the medical insurance review; if the terminal determines that the special medicine does not meet the medication rules, the terminal determines that the medical insurance claims do not comply with the rules, and the terminal outputs the medical insurance claims review does not by.
  • the claim materials are parsed to obtain claims-related information.
  • the terminal obtains claims-related information (ie, types of diseases, medication information, hospitalization information, etc.) in the claims-related information according to claims-related information.
  • Information such as the amount, to determine whether the medical insurance claims include special medicine claims, if the medical insurance claims include special medicine claims, then determine whether the special medicines meet the rules of medication, this application for medical insurance audits carefully reviewed to meet the special medicines.
  • the medication rules have realized a comprehensive and accurate medical insurance claims review for medical insurance drugs.
  • This embodiment is a refinement of step S20 in the first embodiment.
  • analysis of the claim materials is given to obtain claim-related information, and according to the claim-related information, it is determined whether the medical insurance claims include special medicines
  • the specific realization method of claims, the medical insurance audit method based on data analysis includes:
  • Step S21 Preprocess the claim material and extract feature information in the claim material after preprocessing.
  • the claim material is preprocessed, wherein the claim material is the claim material uploaded by the user in the first embodiment, which is not described in detail in this embodiment; the terminal performs preprocessing on the claim material containing text for subsequent feature information Extraction, text information recognition.
  • the main purpose of preprocessing the claim material in this embodiment is to reduce the useless information in the image, so as to facilitate subsequent processing.
  • the preprocessing of claim materials includes the following sub-steps: grayscale (if a color image), noise reduction, binarization, character segmentation, and normalization. Specifically, after binarization, the image only has two colors, black and white, one of which is the background of the image, and the other color is the text to be recognized. In the process of preprocessing, noise reduction is also involved (the noise reduction has a great influence on the extraction of feature information).
  • the terminal divides the information obtained by noise reduction into characters, that is, splits the text in the image into a single text Recognition is recognized word by word.
  • the pre-processing also includes normalization processing, which normalizes individual text images to the same size and applies a unified algorithm under the same specification.
  • the terminal extracts the feature information in the claim material after pre-processing.
  • the feature information is the key information used to identify the text. Each different text can be distinguished from other text by the feature information.
  • the terminal may have to perform feature dimensionality reduction. If the dimension of the feature information is too high (features are generally represented by a vector, the dimension is the number of components of the vector), the efficiency of recognition will be greatly affected
  • the preprocessing of claim materials is to improve the recognition rate and accuracy.
  • step S22 the feature information is input to a preset character classifier to obtain character information, and the character information is post-processed to obtain claims-related information.
  • set character preset character classifier refers to a preset preset character classifier for character information recognition, which needs to be additionally explained, in this embodiment Before the step, you need to train the preset character classifier, for example, using svm, neural network etc, which will not be repeated in this embodiment); the preset character classifier classifies the feature information to determine the recognition of this feature information Get the corresponding character information into which character.
  • the terminal also needs to perform post-processing on the obtained character information.
  • the post-processing is used to optimize the character information.
  • the classification of the preset character classifier is sometimes not necessarily completely correct, such as the recognition of Chinese characters Because of the existence of near-shaped characters in Chinese characters, it is easy to recognize a word as its near-shaped characters. You can solve this problem in post-processing, and correct it by language model. For example, suppose the character preset character classifier recognizes “where” as “where to save”. Through post-processing language model, you will find that “where to save” is wrong. And then make corrections. Furthermore, you can try to format the recognition results in post-processing. In this embodiment, the claims materials are processed to ensure the accuracy of the obtained claims-related information.
  • Step S23 Extract the drug identifier in the claim-related information, query a preset special medicine identifier set, and determine whether there is a target identifier matching the drug identifier in the preset special medicine identifier set.
  • the terminal After obtaining the claims-related information, the terminal extracts the drug identification in the claims-related information, where the drug identification refers to the identification information used to identify the type of drug, for example, the name of the drug or the unified drug number, and the terminal is based on the drug identification Query a preset special medicine identifier set (the preset special medicine identifier set refers to a preset special medicine identifier information set), and determine whether a target identifier matching the medicine identifier exists in the preset special medicine identifier set, that is, The terminal compares the obtained medicine identifier with the identifiers of each special medicine preset in the preset special medicine identifier set to obtain a comparison result, and the terminal judges that the medical insurance claims include special medicine claims according to the comparison result.
  • the drug identification refers to the identification information used to identify the type of drug, for example, the name of the drug or the unified drug number
  • the terminal is based on the drug identification Query a preset special medicine identifier set (the preset special
  • Step S24 if there is a target identifier matching the medicine identifier in the preset special medicine identifier set, it is determined that the medical insurance claims include special medicine claims.
  • the terminal determines that the user has used special medicines, if the preset special medicines If there is no target identifier matching the medicine identifier in the identifier set, the terminal determines that the user has not used the special medicine, and the medical insurance claims do not include the special medicine claims; in this embodiment, the medical insurance claims are judged by the comparison of the medicine identification information Special medicine claims are included to make the medical insurance review more comprehensive.
  • This embodiment is a step after step S22 in the second embodiment.
  • the medical insurance audit method based on data analysis includes:
  • Step S25 Obtain the user identification in the claims-related information, query a preset medical database, and obtain disease diagnosis and treatment information corresponding to the user identification;
  • the terminal obtains the user identification in the claims-related information, where the user identification refers to the identification information used to uniquely identify the user's identity, for example, the account number of the medical insurance account, the user ID number, and the terminal queries the preset based on the user identification
  • the medical database wherein the preset medical database refers to a hospital database that is pre-communicated with the terminal, and the terminal acquires disease diagnosis and treatment information corresponding to the user identification in the preset medical database.
  • Step S26 comparing the disease diagnosis and treatment information with the disease information in the claims-related information to determine whether the claims-related information is true;
  • the terminal compares the disease diagnosis and treatment information acquired from the preset medical database with the disease information in the claim-related information to determine whether the claim-related information is true, that is, if the disease diagnosis-treatment information is related to the claim If the disease information in the information does not match, the claim-related information is not true; if the disease diagnosis and treatment information matches the disease information in the claim-related information, the claim-related information is true.
  • Step S27 if the information related to the claim is not true, the medical insurance claim is rejected;
  • the terminal determines that the claim-related information is not true, the medical insurance claim is rejected, that is, the terminal determines that the user's medical insurance material may contain some false information, and the medical insurance claim review fails.
  • the claim-related information executes extraction of the drug ID in the claim-related information, query a preset special drug ID set, and determine whether there is a target ID in the preset special drug ID set that matches the drug ID A step of.
  • the disease diagnosis and treatment information is compared with the claims-related information, and the verification of the claims-related information is realized, which makes the review of medical insurance claims more comprehensive.
  • This embodiment is a refinement of step S30 in the first embodiment.
  • This embodiment provides a specific implementation method for determining whether the special medicine complies with the medication rules if the medical insurance claims include special medicine claims
  • the medical insurance audit methods based on data analysis include:
  • Step S31 if the medical insurance claims include special medicine claims, obtain medical records and prescription information in the claims-related information;
  • the medical records and prescription information in the claims-related information are obtained, that is, the terminal obtains the medical records and prescription information in the claims-related information to determine the user based on the medical records and prescription information The actual medication information.
  • Step S32 Obtain the actual medication information of the special medicine according to the medical record and the prescription information;
  • Step a Obtain the disease information in the medical record and obtain the instructions for using the special medicine in the prescription information;
  • Step b Compare the disease information with the instructions for using the medicine to determine whether the special medicine is symptomatic;
  • Step c if the special medicine is symptomatic, analyze the disease information and the instructions for use of the medicine to obtain the medication time and dosage of the special medicine, and use the medication time and the dosage as actual medication information.
  • the terminal obtains the disease information (disease information: type of disease, cycle of the disease) in the medical record, the terminal determines the special medicine included in the prescription, and obtains the instructions for using the medicine of the special medicine in the prescription information (Instructions for the use of medicines: including the type of medicines, instructions for the use of medicines, the dose of medicines purchased); the terminal compares the disease information with the instructions for the use of medicines to determine whether the special medicine is symptomatic; determine the special medicine at the terminal When symptomatic, the terminal analyzes the disease information and the drug usage instructions, that is, the terminal can determine the patient's medication time and dosage based on the disease information and drug information, and the terminal uses the medication time and dosage as actual medication information.
  • the disease information disease information: type of disease, cycle of the disease
  • the terminal determines the special medicine included in the prescription
  • Step S33 query the preset medicine usage rule table, obtain the standard medication information of the special medicine, and compare the actual medication information with the standard medication information;
  • the terminal queries the preset drug use rule table (the preset drug use rule table refers to a preset preset rule table for storing various types of special drugs).
  • the terminal obtains the standard drug information of the special drugs, that is, the terminal obtains the The drug name, and query the preset drug use rule table to obtain the standard drug information corresponding to the drug name; the terminal compares the actual drug information with the standard drug information to determine whether the special drug meets the drug rules.
  • the terminal compares the actual drug use time and drug use amount in the actual drug use information with the drug use time and drug use amount in the standard drug use information. If any of them does not match, the special drug does not comply with the drug use rules and is output The medical insurance claims review failed; if all match, the special medicine complies with the medication rules.
  • Step S34 if the actual medication information and the standard medication information match, the special medication complies with the medication rules.
  • the special medicine complies with the medication rules; in this embodiment, the conditions corresponding to the special medicine, the use time of the special medicine, and the amount of the special medicine are analyzed to determine Special medicines comply with the medication rules to obtain medical insurance claims audit results, making medical insurance audits more comprehensive and accurate.
  • the medical insurance review method based on data analysis includes:
  • Step S50 if the medical insurance claims do not include the special medicine claims, the medical insurance identification information of the claims-related information is obtained.
  • the medical insurance identification information of the claims-related information is obtained, that is, the terminal determines that the user's medical insurance claims information does not have claims for special drugs, the terminal obtains the medical insurance identification information of the claims-related information, medical insurance identification information Refers to the identification information of the user purchasing medical insurance, for example, the medical insurance number.
  • Step S60 query the preset medical insurance platform to obtain the medical insurance policy corresponding to the medical insurance identification information and the medical insurance type in the medical insurance policy;
  • the terminal queries the preset medical insurance platform (the preset medical insurance platform refers to a pre-set medical insurance management platform in which medical insurance information is recorded), and the terminal obtains the medical insurance policy corresponding to the medical insurance identification information and the medical insurance in the medical insurance policy Type, that is, in this embodiment, the terminal obtains the medical insurance policy purchased by the user, and determines the medical insurance type according to the medical insurance policy.
  • the preset medical insurance platform refers to a pre-set medical insurance management platform in which medical insurance information is recorded
  • the terminal obtains the medical insurance policy corresponding to the medical insurance identification information and the medical insurance in the medical insurance policy Type, that is, in this embodiment, the terminal obtains the medical insurance policy purchased by the user, and determines the medical insurance type according to the medical insurance policy.
  • Step S70 comparing the medical insurance type with the claim type in the claim related information
  • the terminal compares the medical insurance type with the claim type in the claim-related information, and determines whether the user's medical insurance claim is out of range according to the comparison result, if the medical insurance type matches the claim type in the claim-related information , The user’s medical insurance claims are not out of range; vice versa.
  • Step S80 if the medical insurance type matches the claim type in the claim-related information, the medical insurance claim is reviewed and approved.
  • the medical insurance claim review is output and passed. If the medical insurance type does not match the claim type in the claims-related information, the output medical insurance claims review fails, that is, the user's claims are not within the scope of medical insurance; in this embodiment, the medical insurance without special drugs is reviewed To make the medical insurance review more comprehensive.
  • an embodiment of the present application further proposes a medical insurance audit device based on data analysis.
  • the medical insurance audit device based on data analysis includes: The
  • Receiving and reviewing module 10 which is used to receive the review request of medical insurance claims and obtain claim materials to be reviewed;
  • the analysis and judgment module 20 is configured to analyze the claim materials to obtain claims-related information, and determine whether the medical insurance claims include special medicine claims according to the claims-related information;
  • the medicine judgment module 30 is used for judging whether the special medicine complies with the medication rules if the medical insurance claims include special medicine claims;
  • the audit output module 40 is used for outputting medical insurance claims review if the special medicine meets the medication rules.
  • the analysis and judgment module 20 includes:
  • a feature extraction unit which is used for preprocessing the claim material and extracting feature information in the claim material after preprocessing
  • a character recognition unit configured to input the feature information to a preset character classifier to obtain character information, and post-process the character information to obtain claims-related information;
  • the information comparison unit is used to extract the drug identifier in the claim-related information, query a preset special medicine identifier set, and determine whether there is a target identifier matching the drug identifier in the preset special medicine identifier set;
  • the comparison determination unit is configured to determine that the medical insurance claims include special medicine claims if there is a target identifier in the preset special medicine identifier set that matches the medicine identifier.
  • the analysis and judgment module 20 includes:
  • An information obtaining unit configured to obtain the user identification in the claims-related information, query a preset medical database, and obtain disease diagnosis and treatment information corresponding to the user identification;
  • the information determining unit is used to compare the disease diagnosis and treatment information with the disease information in the claim related information to determine whether the claim related information is true;
  • Rejection unit used to reject the medical insurance claim if the information related to the claim is not true
  • the information comparison unit is used to extract the drug identification in the claim related information, query the preset special drug identification set, and determine whether there is any The steps of matching the target identification of the drug identification.
  • the medicine judgment module 30 includes:
  • the information acquisition submodule is used to obtain medical record and prescription information in the claims-related information if the medical insurance claims include special medicine claims;
  • a medication information generating sub-module for obtaining actual medication information of the special medicine according to the medical record and the prescription information
  • Query and comparison sub-module which is used to query the preset medicine usage rule table, obtain the standard medicine information of the special medicine, and compare the actual medicine information with the standard medicine information;
  • the matching determination submodule is configured to: if the actual medication information and the standard medication information match, then the special medication complies with the medication rules.
  • the medication information generating sub-module includes:
  • An obtaining unit configured to obtain disease information in the medical record and obtain instructions for using the special medicine in the prescription information
  • the comparison and judgment unit is used to compare the disease information with the instructions for use of the medicine and judge whether the special medicine is symptomatic;
  • the medicine generating unit is used to analyze the disease information and the instructions for using the medicine if the special medicine is symptomatic, to obtain the medication time and dosage of the special medicine, and use the medication time and dosage as actual Medication information.
  • the receiving audit module 10 includes:
  • Receiving output unit used to receive medical insurance claims review request, and output material upload prompt information to prompt users to upload electronic documents corresponding to medical insurance claims;
  • a receiving judgment unit configured to receive the electronic document uploaded by the user, and judge whether the electronic document complies with preset screening rules
  • a prompt uploading unit configured to output prompt information to prompt the user to re-upload if the electronic document does not meet the preset screening rules
  • the obtaining unit is configured to use the electronic document as claim material to be reviewed if the electronic document meets the preset screening rule.
  • the medical insurance audit device based on data analysis includes:
  • the medical insurance acquisition module is used to obtain medical insurance identification information of claims-related information if the medical insurance claims do not include special medicine claims;
  • the insurance policy query module is used to query a preset medical insurance platform to obtain the medical insurance policy corresponding to the medical insurance identification information and the medical insurance type in the medical insurance policy;
  • a comparison module used to compare the medical insurance type with the claim type in the claim related information
  • the verification passing module is used for outputting the medical insurance claim approval if the medical insurance type matches the claim type in the claim related information.
  • embodiments of the present application also provide a computer storage medium.
  • Computer-readable instructions are stored on the computer storage medium, and when the computer-readable instructions are executed by the processor, the operations in the medical insurance audit method based on data analysis provided by the foregoing embodiments are implemented.

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Abstract

一种基于数据分析的医保审核方法、装置、设备和存储介质，该方法包括以下步骤：接收医保理赔的审核请求，获取待审核的理赔材料(S10)；解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔(S20)；若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则(S30)；若所述特药符合用药规则，则输出医保理赔审核通过(S40)。该方法利用OCR技术识别所述理赔材料得到理赔相关信息，然后对理赔相关信息分析，进行医保理赔审核，该方法在医保审核中细致审核到用药规则，实现了全面、准确地医保审核。

Description

基于数据分析的医保审核方法、装置、设备和存储介质
本申请要求于2018年12月13日提交中国专利局、申请号为201811529288.6、发明名称为“基于数据分析的医保审核方法、装置、设备和存储介质”的中国专利申请的优先权，其全部内容通过引用结合在申请中。
技术领域
本申请涉及医保管理领域，尤其涉及基于数据分析的医保审核方法、装置、设备和存储介质。
背景技术
传统的医保审核大多是依赖人工审核，由于人力资源有限而医保审核单据数量庞大，导致医保审核周期过长，因此，出现了医保审核平台。
当前的医保审核平台功能过于简单，无法应对实际审核过程中出现的各类特殊问题。即，当前的审核平台通常针对医保材料的真伪，报销范围等进行审核；这样的医保审核并不全面，容易出现医保单据审核错误的问题，如何全面、准确地医保审核成为了当前亟待解决的技术问题。
发明内容
本申请的主要目的在于提供基于数据分析的医保审核方法、装置、设备和存储介质，旨在实现全面、准确地医保理赔审核。
为实现上述目的，本申请提供基于数据分析的医保审核方法，所述基于数据分析的医保审核方法包括以下步骤：
接收医保理赔的审核请求，获取待审核的理赔材料；
解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
若所述特药符合用药规则，则输出医保理赔审核通过。
此外，为实现上述目的，本申请还提供一种基于数据分析的医保审核装置，所述基于数据分析的医保审核装置包括：
接收审核模块，用于接收医保理赔的审核请求，获取待审核的理赔材料；
解析判断模块，用于解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
药品判断模块，用于若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
审核输出模块，用于若所述特药符合用药规则，则输出医保理赔审核通过。
此外，为实现上述目的，本申请还提供一种基于数据分析的医保审核设备；
所述基于数据分析的医保审核设备包括：存储器、处理器及存储在所述存储器上并可在所述处理器上运行的计算机可读指令，其中：
所述计算机可读指令被所述处理器执行时实现如上所述的基于数据分析的医保审核方法的步骤。
此外，为实现上述目的，本申请还提供计算机存储介质；
所述计算机存储介质上存储有计算机可读指令，所述计算机可读指令被处理器执行时实现如上述的基于数据分析的医保审核方法的步骤。
本申请实施例提出的一种基于数据分析的医保审核方法、装置、设备和存储介质，终端接收医保理赔的审核请求，获取待审核的理赔材料；解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；若所述特药符合用药规则，则输出医保理赔审核通过，本申请中在进行医保理赔时针对理赔材料进行解析，得到理赔相关信息，终端根据理赔相关信息，即，终端获取理赔相关信息中的理赔种类（疾病种类、用药信息、住院信息等），理赔额度等信息，判断是否医保理赔中是否包含特药理赔，若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则，本申请中针对医保审核中细致审核到特药符合用药规则，实现了针对医保用药实现全面、准确地医保理赔审核。
附图说明
图1是本申请实施例方案涉及的硬件运行环境的装置结构示意图；
图2为本申请基于数据分析的医保审核方法第一实施例的流程示意图；
图3为本申请基于数据分析的医保审核装置一实施例的功能模块示意图。
本申请目的的实现、功能特点及优点将结合实施例，参照附图做进一步说明。
具体实施方式
应当理解，此处所描述的具体实施例仅仅用以解释本申请，并不用于限定本申请。
由于现有医保审核大多是依赖人工审核，面对堆积如山的医保审核单据，传统的人工审核模式已无法应对目前如此庞大的医保数据量。因此，出现了一些医保审核平台，这些审核平台中通常只是针对材料的真伪进行审核，或者对理赔的种类进行审核，在确定理赔材料真实，理赔种类没有超出理赔范围就输出医保理赔通过的结论，并不可以更加全面的进行核查，例如，用户甲使用医保去A医院看病，大夫处方中包含合理剂量的开了药品1，用户甲再去B医院看病，大夫处方中包含合理剂量的开了药品1，然后将用户甲自己使用一部分药品1，另外再将多余的药品1进行转卖赚取中间差价，这样的情况，当前医保审核并不可以进行有效地审核。
本申请提供一种解决方案，使通过对医保材料进行解析，得到理赔相关信息，终端根据理赔相关信息判断所述医保理赔中是否包含特药理赔；若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；若所述特药符合用药规则，则输出医保理赔审核通过。本申请基于数据的分析，实现全面、准确地医保审核。
如图1所示，图1是本申请实施例方案涉及的硬件运行环境的终端（又叫基于数据分析的医保审核设备，其中，基于数据分析的医保审核设备可以是由单独的基于数据分析的医保审核装置构成，也可以是由其他装置与基于数据分析的医保审核装置组合形成）结构示意图。
本申请实施例终端可以固定终端，也可以是移动终端， 如图1所示，该终端可以包括：处理器1001，例如，中央处理器Central Processing Unit，CPU），网络接口1004，用户接口1003，存储器1005，通信总线1002。其中，通信总线1002用于实现这些组件之间的连接通信。用户接口1003可以包括显示屏（Display）、输入单元比如键盘（Keyboard），可选用户接口1003还可以包括标准的有线接口、无线接口。网络接口1004可选的可以包括标准的有线接口、无线接口（如无线保真WIreless-FIdelity，WIFI接口）。存储器1005可以是高速RAM存储器，也可以是稳定的存储器（non-volatile memory），例如，磁盘存储器。存储器1005可选的还可以是独立于前述处理器1001的存储装置。
本领域技术人员可以理解，图1中示出的终端结构并不构成对终端的限定，可以包括比图示更多或更少的部件，或者组合某些部件，或者不同的部件布置。
如图1所示，该计算机软件产品存储在一个存储介质（存储介质：又叫计算机存储介质、计算机介质、可读介质、可读存储介质、计算机可读存储介质或者直接叫介质等，可以为非易失性可读存储介质、如RAM、磁碟、光盘）中，包括若干指令用以使得一台终端设备执行本申请各个实施例所述的方法，作为一种计算机存储介质的存储器1005中可以包括操作系统、网络通信模块、用户接口模块以及计算机可读指令。
在图1所示的终端中，网络接口1004主要用于连接后台服务器，与后台服务器进行数据通信；用户接口1003主要用于连接客户端（用户端），与客户端进行数据通信；而处理器1001可以用于调用存储器1005中存储的计算机可读指令，并执行本申请以下实施例提供的基于数据分析的医保审核方法中的步骤。
本申请基于数据分析的医保审核方法的第一实施例中，所述基于数据分析的医保审核方法包括：
接收医保理赔的审核请求，获取待审核的理赔材料；
解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
若所述特药符合用药规则，则输出医保理赔审核通过。
本申请中用户购买社会医疗保险或者商业医疗保险之后，在用户出现对应的医疗理赔事件时，用户触发医保理赔的审核请求，终端接收医保理赔的审核请求，并对应显示材料输入页面，以供用户输入理赔材料，终端获取用户输入的理赔材料，并对对理赔材料进行审核，判断用户申请的医保理赔是否符合理赔标准，具体地：
参照图2，本申请基于数据分析的医保审核方法的第一实施例中，所述基于数据分析的医保审核方法包括：
步骤S10，接收医保理赔的审核请求，获取待审核的理赔材料。
终端接收医保理赔的审核请求，其中，医保理赔的审核请求的触发方式多种多样，本实施例中不作限定，例如，用户在终端一指定的应用软件的界面上触发医保理赔的审核请求，或者用户口头命令触发医保理赔的审核请求，在终端接收到医保理赔的审核请求时，终端显示医保理赔材料上传的提示信息，用户根据提示信息在医保理赔界面上上传医保险相关的理赔材料，终端获取用户上传的理赔材料作为待审核的理赔材料。
其中，所述理赔材料中包括：1、保险合同原件；2、被保险人的身份证件原件；3、填写理赔申请资料，包括：理赔申请书、授权委托书(如有代办)、委托银行转账申请书；4、被保险人在医院门诊或住院期间发生的治疗费用收据原件及收据对应的清单；5、定点医院的诊疗记录(如门诊病历原件和住院结束后的住院病历复印件、出院小结、诊断证明、各种检查报告等)；6、因意外或疾病死亡以及残疾，还需提供意外事故证明、死亡证明以及指定的残疾鉴定机构鉴定证明等。
进一步地，在本实施例终端预设筛选规则，其中，预置筛选规则可以根据具体场景设置，例如，预设筛选规则中包括清晰度规则，终端通过预设筛选规则对用户上传的电子材料进行初次筛选，并将符合预设筛选规则的电子材料作为待审核的理赔材料，以进行理赔材料的审核，具体地：
步骤a，接收医保理赔的审核请求，输出材料上传提示信息，以提示用户上传医保理赔对应的电子文档；
步骤b，接收所述用户上传的电子文档，判断所述电子文档是否符合预设筛选规则；
步骤c，若所述电子文档不符合所述预设筛选规则，则输出提示信息，以提示所述用户重新上传；
步骤d，若所述电子文档符合所述预设筛选规则，则将所述电子文档作为待审核的理赔材料。
即，终端接收医保理赔的审核请求，终端输出材料上传提示信息，以提示用户上传医保理赔对应的电子文档；用户上传相关的电子文档，终端接收所述用户上传的电子文档，终端根据预设的筛选规则对用户上传的电子文档进行筛选，即，终端将电子文档的属性信息和预设筛选规则进行比对，得到比对结果，终端根据比对结果判断所述电子文档是否符合预设筛选规则；若所述电子文档不符合所述预设筛选规则，例如，用户上传的电子文档格式不符合预设筛选规则，则终端输出提示信息，以提示所述用户重新上传；则若所述电子文档符合所述预设筛选规则，则将所述电子文档作为待审核的理赔材料。
在本实施例中终端接收到接收医保理赔的审核请求之后，终端在界面上显示医保理赔界面，用户可以基于医保理赔界面上上传电子文档，终端设置了预设筛选规则对用户上传的电子文档进行初步审核，本实施例中实现了可读指令节约的原则，有效地避免了由于上传电子文档格式不符合规定，导致的审核周期增长的问题。
步骤S20，解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔。
终端解析所述理赔材料得到理赔相关信息，其中，理赔相关信息包括：用户身份标识信息（例如，用户身份证号码），用户疾病信息（例如，病历本上的疾病记录），用户医保信息（例如，用户的医保类型、医保保单信息），用户用药信息（例如，用户处方信息）等等，本实施例中给出了解析所述理赔材料得到理赔相关信息的具体实现方式：
即，本实施例中利用OCR(Optical Character Recognition，光学字符识别)识别技术对各个理赔材料进行处理；OCR是指电子设备(例如扫描仪或数码相机)检查纸上打印的字符，通过检测暗、亮的模式确定其形状，然后用字符识别方法将形状翻译成计算机文字的过程；具体地：1.先检测和提取文字区域（Text region）；2.接着利用radon hough变换等方法进行文本校正；3.通过投影直方图分割出单行的文本的图片；4.最后针对文本的图片进行字符识别，例如，基于投影直方图极值点作为候选分割点并使用预设字符分类器搜索最佳分割点。在搜索到分割点之后，对于单个字符使用字符识别预设字符分类器。即，调整灰度-二值化-矫正图像-提取特征信息-预设字符分类器(预设字符分类器有决策树、神经网络等等 )。
本实施例中采用OCR识别技术对理赔材料进行处理，不需要人工查看，就可以自动得到的理赔相关信息。
进一步地，在得到理赔相关信息之后，终端根据得到的理赔相关信息判断是否包含特药理赔；其中，特药是指治疗某些特殊疾病的用药，通常情况下特药的价格较高；本实施例中给出了根据所述理赔相关信息，判断所述医保理赔中是否包含特药理赔的具体实现方式：
即，终端获取理赔相关信息中的药品相关信息，终端获取药品相关信息中的药品标识信息，终端将药品标识信息与预设特药标识集合中的各个特药的标识信息进行比对，其中，预设特药标识集合是指预先设置的特药标识信息集合；若预设特药标识集合中存在与药品标识信息匹配的特药标识，则医保理赔中是否包含特药理赔，反之。
步骤S30，若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则。
若终端所述医保理赔中包含特药理赔，则终端需要进行对特药的用药进行审核，判断所述特药是否符合用药规则，以防止特药理赔错误。
具体地，本实施例中给出判断所述特药是否符合用药规则，可以根据特药的药品使用规则进行判断，主要围绕几个方面：1.特药是否对症；2、特药的用药量是否符合标准；3.特药的用药时间是否符合标准，若上述都符合，则终端可以判断所述特药符合用药规则。本实施例中针对特药的用药规则进行审核，考虑到特药的使用标准信息，使得特药的用药审核更加全面细致，避免了特药超额报销的情况。
步骤S40，若所述特药符合用药规则，则输出医保理赔审核通过。
若终端确定所述特药符合用药规则，即，终端判定医保理赔符合规则，终端输出医保理赔审核通过。进一步，在终端确定医保审核通过之后，终端可以进行医保的发放，提高医保的审核效率；若终端确定所述特药不符合用药规则，则终端判定医保理赔不符合规则，终端输出医保理赔审核不通过。
在本实施例在进行医保理赔时针对理赔材料进行解析，得到理赔相关信息，终端根据理赔相关信息，即，终端获取理赔相关信息中的理赔种类（疾病种类、用药信息、住院信息等），理赔额度等信息，判断是否医保理赔中是否包含特药理赔，若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则，本申请中针对医保审核中细致审核到特药符合用药规则，实现了针对医保用药实现全面、准确地医保理赔审核。
进一步的，在本申请第一实施例的基础上，提出了本申请基于数据分析的医保审核方法的第二实施例。
本实施例中是第一实施例中步骤S20的细化，本实施例中给出了解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息，判断所述医保理赔中是否包含特药理赔的具体实现方式，所述基于数据分析的医保审核方法包括：
步骤S21，对所述理赔材料进行预处理，并提取经预处理后所述理赔材料中的特征信息。
本实施例中针对理赔材料进行预处理，其中，理赔材料为第一实施例中用户上传的理赔材料，本实施例中不作赘述；终端对包含文字的理赔材料进行预处理处理以便后续进行特征信息提取、文字信息识别。
本实施例中对所述理赔材料进行预处理的主要目的是减少图像中的无用信息，以便方便后面的处理。理赔材料预处理包括通常有：灰度化（如果是彩色图像）、降噪、二值化、字符切分以及归一化这些子步骤。具体地，经过二值化后，图像只剩下两种颜色，即黑和白，其中一个是图像背景，另一个颜色就是要识别的文字了。在预处理的过程中，还涉及到降噪（降噪的好坏对特征信息提取的影响很大），终端将降噪得到信息进行字符切分，即，将图像中的文字分割成单个文字识别的时候是一个字一个字识别的。此外，预处理还包括归一化处理，归一化处理是将单个的文字图像规整到同样的尺寸，在同一个规格下，应用统一的算法。
在理赔材料预处理之后，终端提取预处理之后所述理赔材料中的特征信息，特征信息是用来识别文字的关键信息，每个不同的文字都能通过特征信息来和其他文字进行区分。在确定了特征信息后，终端有可能要进行特征降维，如果特征信息的维数太高（特征一般用一个向量表示，维数即该向量的分量数），进行识别的效率会受到很大的影响，本实施例中对理赔材料进行预处理是为了提高识别速率和准确率。
步骤S22，将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息。
终端将提取的特征信息输入至预设字符分类器（设字符预设字符分类器是指预设设置的用于进行字符信息识别的预设字符分类器，需要补充说明的是，在本实施例的步骤之前，还需要对预设字符分类器进行训练，例如，利用svm，神经网络etc，本实施例中不作赘述）；预设字符分类器就对特征信息进行分类，确定这个特征信息该识别成哪个文字，得到对应的字符信息。
进一步地，终端还需要对得到的字符信息进行后处理，后处理是用来对字符信息进行优化的，首先，预设字符分类器的分类有时候不一定是完全正确的，比如对汉字的识别，由于汉字中形近字的存在，很容易将一个字识别成其形近字。后处理中可以去解决这个问题，通过语言模型来进行校正，例如，设字符预设字符分类器将“在哪里”识别成“存哪里”，通过后处理语言模型会发现“存哪里”是错误的，然后进行校正。再者，后处理中可以尝试去对识别结果进行格式化。本实施例中将理赔材料进行处理，保证了得到的理赔相关信息的准确性。
步骤S23，提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识。
在得到理赔相关信息之后，终端提取所述理赔相关信息中的药品标识，其中，药品标识是指用于识别药品种类的标识信息，例如，药品的名称或者统一化的药品编号，终端基于药品标识查询预设特药标识集合（预设特药标识集合是指预先设置的特药标识信息集合），判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识，即，终端将得到的药品标识与预设特药标识集合中预设的各个特药的标识进行比对，得到比对结果，终端根据比对结果，判断所述医保理赔中包含特药理赔。
步骤S24，若所述预设特药标识集合中存在与所述药品标识匹配的目标标识，则判定所述医保理赔中包含特药理赔。
若所述预设特药标识集合中存在与所述药品标识匹配的目标标识，则判定所述医保理赔中包含特药理赔，即，终端确定用户使用了特药，若所述预设特药标识集合中不存在与所述药品标识匹配的目标标识，则终端确定用户没有使用了特药，医保理赔中不包含特药理赔；在本实施例中通过药品标识信息的比对，判断医保理赔中包含特药理赔，使得医保审核的更加全面。
进一步的，在本申请第二实施例的基础上，提出了本申请基于数据分析的医保审核方法的第三实施例。
本实施例是第二实施例中步骤S22之后的步骤，在本实施例中为了防止用户上传假的审核材料，具体地，所述基于数据分析的医保审核方法包括：
步骤S25，获取所述理赔相关信息中的用户身份标识，查询预设医疗数据库，获取所述用户身份标识对应的疾病诊疗信息；
终端获取所述理赔相关信息中的用户身份标识，其中，用户身份标识是指用于唯一识别用户身份的标识信息，例如，医保账户的账号，用户身份证号码，终端基于用户身份标识查询预设医疗数据库，其中，预设医疗数据库是指预先与终端通信连接的医院数据库，终端获取预设医疗数据库中所述用户身份标识对应的疾病诊疗信息。
步骤S26，将所述疾病诊疗信息与所述理赔相关信息中的疾病信息进行比对，以判断所述理赔相关信息是否真实；
终端将预设医疗数据库获取的所述疾病诊疗信息与所述理赔相关信息中的疾病信息进行比对，以判断所述理赔相关信息是否真实，即，若所述疾病诊疗信息与所述理赔相关信息中的疾病信息不匹配，则所述理赔相关信息不真实；若所述疾病诊疗信息与所述理赔相关信息中的疾病信息匹配，则所述理赔相关信息真实。
步骤S27，若所述理赔相关信息不真实，则驳回所述医保理赔；
若终端确定所述理赔相关信息不真实，则驳回所述医保理赔，即，终端确定用户的医保材料中可能包含部分虚假信息，医保理赔审核不通过。
若所述理赔相关信息真实，则执行提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识的步骤。在本实施例中针对同将疾病诊疗信息与理赔相关信息进行比对，实现了理赔相关信息真伪的验证，使得医保理赔的审核更加全面。
进一步的，在本申请上述实施例的基础上，提出了本申请基于数据分析的医保审核方法的第四实施例。
本实施例中是第一实施例中步骤S30的细化，本实施例中给出了若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则的具体实现方式，所述基于数据分析的医保审核方法包括：
步骤S31，若所述医保理赔中包含特药理赔，则获取所述理赔相关信息中的病历记录和处方信息；
若所述医保理赔中包含特药理赔，则获取所述理赔相关信息中的病历记录和处方信息，即，终端获取理赔相关信息中的病历记录和处方信息，以根据病历记录和处方信息确定用户的实际用药信息。
步骤S32，根据所述病历记录和所述处方信息，得到所述特药的实际用药信息；
本实施例中根据所述病历记录和所述处方信息，得到所述特药的实际用药信息的具体实现步骤，如下：
步骤a，获取所述病历记录中的疾病信息，获取所述处方信息中所述特药的药品使用说明；
步骤b，将所述疾病信息与所述药品使用说明进行比对，判断所述特药是否对症；
步骤c，若所述特药对症，则分析所述疾病信息和所述药品使用说明，得到所述特药的用药时间和用药量，将所述用药时间和所述用药量作为实际用药信息。
即，终端获取所述病历记录中的疾病信息（疾病信息：疾病种类，疾病所处的周期），终端确定处方中包含的特药，并获取所述处方信息中所述特药的药品使用说明（药品使用说明：包括药品种类，药品使用说明，药品的购买剂量）；终端将所述疾病信息与所述药品使用说明进行比对，判断所述特药是否对症；在终端确定所述特药对症时，终端则分析所述疾病信息和所述药品使用说明，即，终端可以根据疾病信息和药品信息确定患者的用药时间，用药量，终端将用药时间、用药量作为实际用药信息。
步骤S33，查询预设药品使用规则表，获取所述特药的标准用药信息，将所述实际用药信息和所述标准用药信息进行比对；
终端查询预设药品使用规则表（预设药品使用规则表是指预先设置的保存有各类型特药使用规则表），终端获取所述特药的标准用药信息，即，终端获取药品信息中的药品名称，并查询预设药品使用规则表获取该药品名称对应的标准用药信息；终端将所述实际用药信息和所述标准用药信息进行比对，以判断特药符合用药规则。
即，终端将实际用药信息中的实际药品使用时间、药品使用量与标准用药信息中的药品使用时间、药品使用量进行比对，若有任意一个不匹配，则特药不符合用药规则，输出医保理赔审核不通过；若全部匹配，则特药符合用药规则。
步骤S34，若所述实际用药信息和所述标准用药信息匹配，则所述特药符合用药规则。
若所述实际用药信息和所述标准用药信息匹配，则所述特药符合用药规则；在本实施例中根据特药对应的病症，特药的使用时间、特药的使用量进行分析，确定特药符合用药规则，以得到医保理赔审核结果，使得医保审核更加全面，准确。
进一步的，在本申请上述实施例的基础上，提出了本申请基于数据分析的医保审核方法的第五实施例。
本实施例中是第一实施例中步骤S20之后，本实施例中给出了若所述医保理赔中不包含特药理赔的具体实现方式，所述基于数据分析的医保审核方法包括：
步骤S50，若医保理赔中不包含特药理赔，则获取理赔相关信息的医保标识信息。
若医保理赔中不包含特药理赔，则获取理赔相关信息的医保标识信息，即，终端确定用户的医保理赔信息中没有针对特药的理赔，终端获取理赔相关信息的医保标识信息，医保标识信息是指用户购买医保的标识信息，例如，医保编号。
步骤S60，查询预设医疗保险平台，获取所述医保标识信息对应的医保保单及所述医保保单中的医保类型；
终端查询预设医疗保险平台（预设医疗保险平台是指预先设置的医疗保险管理平台，其中记录有医疗保险信息），终端获取所述医保标识信息对应的医保保单及所述医保保单中的医保类型，即，本实施例中终端获取用户购买的医保保单，并根据医保保单确定医保类型。
步骤S70，将所述医保类型与所述理赔相关信息中的理赔类型进行比对；
终端将所述医保类型与所述理赔相关信息中的理赔类型进行比对，并根据比对结果判断用户的医保理赔是否超范围，若所述医保类型与所述理赔相关信息中的理赔类型匹配，则用户的医保理赔没有超范围；反之。
步骤S80，若所述医保类型与所述理赔相关信息中的理赔类型匹配，则输出医保理赔审核通过。
若所述医保类型与所述理赔相关信息中的理赔类型匹配，则输出医保理赔审核通过。若所述医保类型与所述理赔相关信息中的理赔类型不匹配，则输出医保理赔审核不通过，即，用户的理赔不在医保的范围内；在本实施例中针对没有特药的医保进行审核，使得医保审核更加全面。
此外，参考图3，本申请实施例还提出一种基于数据分析的医保审核装置，所述基于数据分析的医保审核装置包括：
接收审核模块10，用于接收医保理赔的审核请求，获取待审核的理赔材料；
解析判断模块20，用于解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
药品判断模块30，用于若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
审核输出模块40，用于若所述特药符合用药规则，则输出医保理赔审核通过。
可选地，所述解析判断模块20，包括：
特征提取单元，用于对所述理赔材料进行预处理，并提取经预处理后所述理赔材料中的特征信息；
字符识别单元，用于将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息；
信息比对单元，用于提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识；
比对判定单元，用于若所述预设特药标识集合中存在与所述药品标识匹配的目标标识，则判定所述医保理赔中包含特药理赔。
可选地，所述解析判断模块20，包括：
信息获取单元，用于获取所述理赔相关信息中的用户身份标识，查询预设医疗数据库，获取所述用户身份标识对应的疾病诊疗信息；
信息判定单元，用于将所述疾病诊疗信息与所述理赔相关信息中的疾病信息进行比对，以判断所述理赔相关信息是否真实；
驳回单元，用于若所述理赔相关信息不真实，则驳回所述医保理赔；
信息比对单元，用于若所述理赔相关信息真实，则执行提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识的步骤。
可选地，所述药品判断模块30，包括：
信息获取子模块，用于若所述医保理赔中包含特药理赔，则获取所述理赔相关信息中的病历记录和处方信息；
用药信息生成子模块，用于根据所述病历记录和所述处方信息，得到所述特药的实际用药信息；
查询比对子模块，用于查询预设药品使用规则表，获取所述特药的标准用药信息，将所述实际用药信息和所述标准用药信息进行比对；
匹配确定子模块，用于若所述实际用药信息和所述标准用药信息匹配，则所述特药符合用药规则。
可选地，所述用药信息生成子模块，包括：
获取单元，用于获取所述病历记录中的疾病信息，获取所述处方信息中所述特药的药品使用说明；
比对判断单元，用于将所述疾病信息与所述药品使用说明进行比对，判断所述特药是否对症；
用药生成单元，用于若所述特药对症，则分析所述疾病信息和所述药品使用说明，得到所述特药的用药时间和用药量，将所述用药时间和所述用药量作为实际用药信息。
可选地，接收审核模块10，包括：
接收输出单元，用于接收医保理赔的审核请求，输出材料上传提示信息，以提示用户上传医保理赔对应的电子文档；
接收判断单元，用于接收所述用户上传的电子文档，判断所述电子文档是否符合预设筛选规则；
提示上传单元，用于若所述电子文档不符合所述预设筛选规则，则输出提示信息，以提示所述用户重新上传；
获取单元，用于若所述电子文档符合所述预设筛选规则，则将所述电子文档作为待审核的理赔材料。
可选地，所述基于数据分析的医保审核装置，包括：
医保获取模块，用于若医保理赔中不包含特药理赔，则获取理赔相关信息的医保标识信息；
保单查询模块，用于查询预设医疗保险平台，获取所述医保标识信息对应的医保保单及所述医保保单中的医保类型；
比对模块，用于将所述医保类型与所述理赔相关信息中的理赔类型进行比对；
审核通过模块，用于若所述医保类型与所述理赔相关信息中的理赔类型匹配，则输出医保理赔审核通过。
其中，基于数据分析的医保审核装置的各个功能模块实现的步骤可参照本申请基于数据分析的医保审核方法的各个实施例，此处不再赘述。
此外，本申请实施例还提出一种计算机存储介质。
所述计算机存储介质上存储有计算机可读指令，所述计算机可读指令被处理器执行时实现上述实施例提供的基于数据分析的医保审核方法中的操作。
以上仅为本申请的优选实施例，并非因此限制本申请的专利范围，凡是利用本申请说明书及附图内容所作的等效结构或等效流程变换，或直接或间接运用在其他相关的技术领域，均同理包括在本申请的专利保护范围内。

Claims (20)

  1. 一种基于数据分析的医保审核方法，其特征在于，所述基于数据分析的医保审核方法包括以下步骤：
    接收医保理赔的审核请求，获取待审核的理赔材料；
    解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
    若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
    若所述特药符合用药规则，则输出医保理赔审核通过。
  2. 如权利要求1所述的基于数据分析的医保审核方法，其特征在于，所述解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔的步骤，包括：
    对所述理赔材料进行预处理，并提取经预处理后所述理赔材料中的特征信息；
    将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息；
    提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识；
    若所述预设特药标识集合中存在与所述药品标识匹配的目标标识，则判定所述医保理赔中包含特药理赔。
  3. 如权利要求2所述的基于数据分析的医保审核方法，其特征在于，所述将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息的步骤之后，包括：
    获取所述理赔相关信息中的用户身份标识，查询预设医疗数据库，获取所述用户身份标识对应的疾病诊疗信息；
    将所述疾病诊疗信息与所述理赔相关信息中的疾病信息进行比对，以判断所述理赔相关信息是否真实；
    若所述理赔相关信息不真实，则驳回所述医保理赔；
    若所述理赔相关信息真实，则执行提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识的步骤。
  4. 如权利要求1所述的基于数据分析的医保审核方法，其特征在于，所述若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则的步骤，包括：
    若所述医保理赔中包含特药理赔，则获取所述理赔相关信息中的病历记录和处方信息；
    根据所述病历记录和所述处方信息，得到所述特药的实际用药信息；
    查询预设药品使用规则表，获取所述特药的标准用药信息，将所述实际用药信息和所述标准用药信息进行比对；
    若所述实际用药信息和所述标准用药信息匹配，则所述特药符合用药规则。
  5. 如权利要求4所述的基于数据分析的医保审核方法，其特征在于，所述根据所述病历记录和所述处方信息，得到所述特药的实际用药信息的步骤，包括：
    获取所述病历记录中的疾病信息，获取所述处方信息中所述特药的药品使用说明；
    将所述疾病信息与所述药品使用说明进行比对，判断所述特药是否对症；
    若所述特药对症，则分析所述疾病信息和所述药品使用说明，得到所述特药的用药时间和用药量，将所述用药时间和所述用药量作为实际用药信息。
  6. 如权利要求1所述的基于数据分析的医保审核方法，其特征在于，所述接收医保理赔的审核请求，获取待审核的理赔材料的步骤，包括：
    接收医保理赔的审核请求，输出材料上传提示信息，以提示用户上传医保理赔对应的电子文档；
    接收所述用户上传的电子文档，判断所述电子文档是否符合预设筛选规则；
    若所述电子文档不符合所述预设筛选规则，则输出提示信息，以提示所述用户重新上传；
    若所述电子文档符合所述预设筛选规则，则将所述电子文档作为待审核的理赔材料。
  7. 如权利要求1所述的基于数据分析的医保审核方法，其特征在于，所述解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔的步骤之后，包括：
    若医保理赔中不包含特药理赔，则获取理赔相关信息的医保标识信息；
    查询预设医疗保险平台，获取所述医保标识信息对应的医保保单及所述医保保单中的医保类型；
    将所述医保类型与所述理赔相关信息中的理赔类型进行比对；
    若所述医保类型与所述理赔相关信息中的理赔类型匹配，则输出医保理赔审核通过。
  8. 一种基于数据分析的医保审核装置，其特征在于，所述基于数据分析的医保审核装置包括：
    接收审核模块，用于接收医保理赔的审核请求，获取待审核的理赔材料；
    解析判断模块，用于解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
    药品判断模块，用于若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
    审核输出模块，用于若所述特药符合用药规则，则输出医保理赔审核通过。
  9. 如权利要求8所述的基于数据分析的医保审核装置，其特征在于，所述解析判断模块，包括：
    特征提取单元，用于对所述理赔材料进行预处理，并提取经预处理后所述理赔材料中的特征信息；
    字符识别单元，用于将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息；
    信息比对单元，用于提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识；
    比对判定单元，用于若所述预设特药标识集合中存在与所述药品标识匹配的目标标识，则判定所述医保理赔中包含特药理赔。
  10. 如权利要求9所述的基于数据分析的医保审核装置，其特征在于，所述解析判断模块，包括：
    信息获取单元，用于获取所述理赔相关信息中的用户身份标识，查询预设医疗数据库，获取所述用户身份标识对应的疾病诊疗信息；
    信息判定单元，用于将所述疾病诊疗信息与所述理赔相关信息中的疾病信息进行比对，以判断所述理赔相关信息是否真实；
    驳回单元，用于若所述理赔相关信息不真实，则驳回所述医保理赔；
    信息比对单元，用于若所述理赔相关信息真实，则执行提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识的步骤。
  11. 如权利要求8所述的基于数据分析的医保审核装置，其特征在于，所述药品判断模块，包括：
    信息获取子模块，用于若所述医保理赔中包含特药理赔，则获取所述理赔相关信息中的病历记录和处方信息；
    用药信息生成子模块，用于根据所述病历记录和所述处方信息，得到所述特药的实际用药信息；
    查询比对子模块，用于查询预设药品使用规则表，获取所述特药的标准用药信息，将所述实际用药信息和所述标准用药信息进行比对；
    匹配确定子模块，用于若所述实际用药信息和所述标准用药信息匹配，则所述特药符合用药规则。
  12. 如权利要求11所述的基于数据分析的医保审核装置，其特征在于，所述用药信息生成子模块，包括：
    获取单元，用于获取所述病历记录中的疾病信息，获取所述处方信息中所述特药的药品使用说明；
    比对判断单元，用于将所述疾病信息与所述药品使用说明进行比对，判断所述特药是否对症；
    用药生成单元，用于若所述特药对症，则分析所述疾病信息和所述药品使用说明，得到所述特药的用药时间和用药量，将所述用药时间和所述用药量作为实际用药信息。
  13. 如权利要求8所述的基于数据分析的医保审核装置，其特征在于，接收审核模块，包括：
    接收输出单元，用于接收医保理赔的审核请求，输出材料上传提示信息，以提示用户上传医保理赔对应的电子文档；
    接收判断单元，用于接收所述用户上传的电子文档，判断所述电子文档是否符合预设筛选规则；
    提示上传单元，用于若所述电子文档不符合所述预设筛选规则，则输出提示信息，以提示所述用户重新上传；
    获取单元，用于若所述电子文档符合所述预设筛选规则，则将所述电子文档作为待审核的理赔材料。
  14. 如权利要求8所述的基于数据分析的医保审核装置，其特征在于，所述基于数据分析的医保审核装置，包括：
    医保获取模块，用于若医保理赔中不包含特药理赔，则获取理赔相关信息的医保标识信息；
    保单查询模块，用于查询预设医疗保险平台，获取所述医保标识信息对应的医保保单及所述医保保单中的医保类型；
    比对模块，用于将所述医保类型与所述理赔相关信息中的理赔类型进行比对；
    审核通过模块，用于若所述医保类型与所述理赔相关信息中的理赔类型匹配，则输出医保理赔审核通过。
  15. 一种基于数据分析的医保审核设备，其特征在于，所述基于数据分析的医保审核设备包括：存储器、处理器及存储在所述存储器上并可在所述处理器上运行的计算机可读指令，其中：
    所述计算机可读指令被所述处理器执行时实现以下的步骤：
    接收医保理赔的审核请求，获取待审核的理赔材料；
    解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
    若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
    若所述特药符合用药规则，则输出医保理赔审核通过。
  16. 如权利要求15所述的基于数据分析的医保审核设备，其特征在于，所述计算机可读指令被所述处理器执行所述解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔的步骤，包括：
    对所述理赔材料进行预处理，并提取经预处理后所述理赔材料中的特征信息；
    将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息；
    提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识；
    若所述预设特药标识集合中存在与所述药品标识匹配的目标标识，则判定所述医保理赔中包含特药理赔。
  17. 如权利要求16所述的基于数据分析的医保审核设备，其特征在于，所述计算机可读指令被所述处理器执行所述将所述特征信息输入至预设字符分类器，得到字符信息，并将所述字符信息进行后处理，得到理赔相关信息的步骤之后，包括：
    获取所述理赔相关信息中的用户身份标识，查询预设医疗数据库，获取所述用户身份标识对应的疾病诊疗信息；
    将所述疾病诊疗信息与所述理赔相关信息中的疾病信息进行比对，以判断所述理赔相关信息是否真实；
    若所述理赔相关信息不真实，则驳回所述医保理赔；
    若所述理赔相关信息真实，则执行提取所述理赔相关信息中的药品标识，查询预设特药标识集合，判断所述预设特药标识集合中是否存在与所述药品标识匹配的目标标识的步骤。
  18. 如权利要求15所述的基于数据分析的医保审核设备，其特征在于，所述计算机可读指令被所述处理器执行所述若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则的步骤，包括：
    若所述医保理赔中包含特药理赔，则获取所述理赔相关信息中的病历记录和处方信息；
    根据所述病历记录和所述处方信息，得到所述特药的实际用药信息；
    查询预设药品使用规则表，获取所述特药的标准用药信息，将所述实际用药信息和所述标准用药信息进行比对；
    若所述实际用药信息和所述标准用药信息匹配，则所述特药符合用药规则。
  19. 如权利要求18所述的基于数据分析的医保审核设备，其特征在于，所述计算机可读指令被所述处理器执行所述根据所述病历记录和所述处方信息，得到所述特药的实际用药信息的步骤，包括：
    获取所述病历记录中的疾病信息，获取所述处方信息中所述特药的药品使用说明；
    将所述疾病信息与所述药品使用说明进行比对，判断所述特药是否对症；
    若所述特药对症，则分析所述疾病信息和所述药品使用说明，得到所述特药的用药时间和用药量，将所述用药时间和所述用药量作为实际用药信息。
  20. 一种计算机存储介质，其特征在于，所述计算机存储介质上存储有计算机可读指令，所述计算机可读指令被处理器执行时实现以下的步骤：
    接收医保理赔的审核请求，获取待审核的理赔材料；
    解析所述理赔材料得到理赔相关信息，根据所述理赔相关信息判断所述医保理赔中是否包含特药理赔；
    若所述医保理赔中包含特药理赔，则判断所述特药是否符合用药规则；
    若所述特药符合用药规则，则输出医保理赔审核通过。
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