System and method for detecting fraudulent transactions in medical insurance outpatient services

Abstract

The invention discloses a system and method for detecting fraudulent transactions in medical insurance outpatient services. In the invention, a data processing unit, a score calculating unit and a detecting unit are sequentially connected in series; the detecting unit comprises two modules which conform to transaction rules and probability of the fraudulent transactions; the output of a data dictionary is connected with the data processing unit; the input of an algorithm library is connected with the score calculating unit; the output of an action rule library and the output of a transaction rule library are respectively connected with the detecting unit; a rule management unit is connected between the action rule library and the transaction rule library; and the system is connected inside or outside a business processing system of a medical insurance institution for detecting, when the system is connected on the outside, a transaction information extraction module is arranged in front of the data processing unit for carrying out analysis, inquiry and statistics on the history of actions which are detected to be abnormal. By detecting the medical transaction rules in the outpatient services and evaluating the transaction fraudulence unlawful actions, the quantitative basis can be provided for defining the medical fraudulence unlawful actions, and the supervision cost of medical insurance fraudulence and unlawful phenomena can be reduced.

Description

Technical field [0001] The invention involves the medical insurance information processing system, which specifically involves a computer system and method for detecting the abnormal phenomenon of medical insurance outpatient medical behavior. Background technique [0002] In the medical insurance social security system, tens of thousands of outpatient medical behavior trading data occur every day.The implementation of these transactions includes: payment transactions between insurers and medical institutions, payment transactions between medical institutions and insurance institutions.Each payment transaction involves the value exchange of currency, check or medical insurance card.At present, there is a disadvantage of using the existing medical insurance information processing system to process these payment transactions, that is, it is impossible to identify which payment transactions are obtained from medical behavior to obtain benefits from medical behavior.These fraud behav...

AI Technical Summary

Problems solved by technology

In fact, in a medium-sized city, there are thousands of transaction data of outpatient medical behaviors occurring every day. Obviously, to supervise medical fraud and violations according to the above-mentioned supervision method will not only require expensive supervision costs, but also Moreover, it is impossible to effectively detect violations and frauds in real time, and it is difficult to effectively curb the occurrence of medical insurance frauds and violations

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