A monitoring system and monitoring method for medical insurance reimbursement behavior
A monitoring system and medical insurance technology, applied in the field of medical insurance management system, can solve the problems of medical insurance fund loss, easy omission of reimbursement receipt data, etc., and achieve the effect of preventing losses
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Embodiment 1
[0037] combine figure 1 and figure 2 As shown, in this embodiment, the data support subsystem 1 includes a server 11, and the server 11 is used to provide responsible person qualification data, and the responsible person qualification data includes hospital qualification information, doctor qualification information and insured person qualification information , the verification audit subsystem 2 includes a qualification verification module, and the qualification verification module includes a first input unit 10, a verification unit 12 and a verification result output unit 13 generated by a computer program, in:
[0038] The first input unit 10 is used for inputting the reimbursement receipt data, so that the verification unit 12 checks and audits the reimbursement receipt data, and the reimbursement receipt data includes hospital information, doctor information and insured person information;
[0039] The verification unit 12 is used to obtain the reimbursement receipt da...
Embodiment 2
[0052] combine figure 1 and Figure 4 As shown, the data support subsystem 1 includes a server 11, and the server 11 is used to store the rule data list and the threshold value of each rule data, and the verification audit subsystem 2 includes a rule checking module, and the rules therein are Refers to the data groups defined by the system maintenance personnel based on information such as the insured population, diagnosis and treatment items, drug parameters, medical expenses, and drug quantities based on experience, and stored in the database with these data groups as standards. When the insured provides medical insurance reimbursement When processing the receipt, compare each item of data in the medical insurance reimbursement receipt with the corresponding rules in the database, and then determine whether the medical behavior violates the regulations.
[0053] The rule verification module includes a rule definition unit 20 generated by a computer program, a second input u...
Embodiment 3
[0071] combine figure 1 and Figure 5 As shown, in the present embodiment, the verification audit subsystem 2 includes a suspicious behavior audit module, and the suspicious behavior audit module includes a consumption information base 30 generated by a computer program, a retrieval unit 31, and a fee screening unit 32 , an analysis execution unit 33, a human-computer interaction unit 34, a knowledge base 35 and a historical information base 36, wherein:
[0072] The consumption information library 30 is used to store the reimbursement documents to be reviewed generated by the insured person during the medical consumption process;
[0073] The retrieval unit 31 is used to obtain the reimbursement documents to be reviewed by the insured person from the consumption information database 30, and the reimbursement documents to be reviewed include medical registration information, prescription detailed information and fee settlement information;
[0074] The cost screening unit 32...
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