A suspicious behavior review system and review method in the process of medical insurance reimbursement

Abstract

The invention discloses a suspicious behavior review system in the process of medical insurance reimbursement, which includes a consumption information base, a retrieval unit, an expense screening unit, an analysis execution unit, and a human-computer interaction unit. The retrieval unit can automatically obtain information from the consumption information base For the reimbursement documents to be reviewed, use the cost screening unit to classify multiple data in the prescription details, and display the medical registration information, fee settlement information and classified prescription details in the human-computer interaction unit, so that the auditors can be intuitive At the same time, by inputting the parameters and thresholds corresponding to the various data in the prescription detailed information to the analysis and execution unit, the analysis and execution unit can automatically review the various data in the prescription detailed information, realizing multiple data Batch processing greatly reduces the time for manual review, so that with the assistance of the review system, efficient, fast and accurate review of medical insurance reimbursement documents can be realized.

Description

technical field [0001] The invention relates to an audit system and an audit method for medical insurance reimbursement documents, in particular to an audit system and an audit method for suspicious behavior in the process of medical insurance reimbursement. Background technique [0002] In order to maintain the integrity of the basic medical insurance fund and protect the insured to fully enjoy the basic medical insurance benefits, the medical management department has made clear responsibilities for violations of the basic medical insurance regulations by medical institutions, doctors, and insured persons. , in order to prevent the responsible person from defrauding the medical insurance fund, for example: in the medical insurance settlement documents, the medicines prescribed belong to the contraindicated drugs of the insured person, or are not used to treat the diseases suffered by the insured person; The department has handled multiple admissions in a row and so on. In...

AI Technical Summary

Problems solved by technology

In the existing technology, the review and verification of medical insurance reimbursement documents are manually reviewed, that is, the review personnel check the reimbursement documents one by one, the review speed and review quality are low, and it is easy to miss illegal reimbursement document data, resulting in a large number of Suspicious behaviors such as fraud, abuse, waste, etc., resulting in losses of medical insurance funds

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