Medical insurance claims management method

Abstract

The invention relates to a claims system, in particular relating to a medical insurance claims management method which comprises the following steps: firstly verifying the identity information of a client, inputting medical data of the client in a social insurance data platform, then automatically accounting based on an algorithm configured by a system, then synthesizing the accounted data into claim data, and storing the claims data in the client information; and finally automatically completing cost segmentation according to the synthesized claims data. By using the medical insurance claims management method, the work efficiency is improved, the operation cost is reduced, the risk control capacity is improved, and the automated immediate claims can be provided for the client.

Description

technical field [0001] The invention relates to a claim settlement system, in particular to a medical insurance claim settlement management method. Background technique [0002] China's commercial health insurance is all managed by life insurance companies, and the few health insurance companies in the market do not break away from the management framework of life insurance companies, and do not have an independent health insurance business management system. Commercial insurance management methods have the following deficiencies: [0003] 1. The health insurance configuration module currently used by industry insurance companies is a module shared with the production and life insurance system. It functions to configure simple adjustment parameters such as deductibles and compensation ratios. For compensation related to disease diagnosis, drugs, and medical institutions parameters, the system is difficult to configure, and the result is that the automatic claim review and a...

AI Technical Summary

Problems solved by technology

[0003] 1. The health insurance configuration module currently used by industry insurance companies is a module shared with the production and life insurance system. It functions to configure simple adjustment parameters such as deductibles and compensation ratios. For compensation related to disease diagnosis, drugs, and medical institutions parameters, the system is difficult to configure, and the result is that the automatic claim review and adjustment functions of the system cannot be realized, requiring many claimants to manually review and adjust

[0004] 2. Since the health systems of insurance companies and TPA companies are heavily dependent on the core business system of life insurance, health insurance product liability and claim settlement rules can only be defined in the system to a limited extent. Therefore, the systems of companies currently engaged in commercial health insurance management are automatically The rate of audit and adjustment is very low. Like Ping An Insurance, which has a leading system, the probability of automatic claim settlement by the system is less than 20%. Most other companies require 100% manual audit.

The automatic settlement function of the local system of basic medical care for urban employees, new rural cooperative medical insurance, and resident medical insurance is relatively complete, but the medical expenses for medical treatment in other places and transfers to other places are currently all manually reviewed and settled, and the system lacks corresponding processing capabilities

[0005] 3. At present, the medical insurance operating companies and social security management agencies in the market have not set up the cost rationality review function in the system, and the payment is completely based on the medical institution's cost details. There is no system for prescribing medicines by car, overdose, unreasonable diagnosis, etc. review

[0006] 4. At present, all business and management parties in the market can analyze medical insurance compensation data, but due to the difficulty of data collection, the granularity of data is relatively coarse, and the depth and breadth of data analysis are relatively low

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