A rule verification system and verification method for identifying medical insurance reimbursement violations

A rule and medical insurance technology, applied in data processing applications, instruments, calculations, etc., can solve problems such as easy omission of reimbursement document data, loss of medical insurance funds, etc., to improve the efficiency of rule verification, keep clarity, and reduce repeated data acquisition The effect of times

A rule and medical insurance technology, applied in data processing applications, instruments, calculations, etc., can solve problems such as easy omission of reimbursement document data, loss of medical insurance funds, etc., to improve the efficiency of rule verification, keep clarity, and reduce repeated data acquisition The effect of times

CN104182824BActive Publication Date: 2018-02-06PING AN MEDICAL & HEALTHCARE MANAGEMENT CO LTD +1
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  • A rule verification system and verification method for identifying medical insurance reimbursement violations

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Embodiment Construction

[0012] The present invention will be described in more detail below in conjunction with the accompanying drawings and embodiments.

[0013] The invention discloses a rule verification system for identifying violations of medical insurance reimbursement, wherein the rules refer to the data defined by the system maintenance personnel based on the experience of the insured population, diagnosis and treatment items, drug parameters, medical expenses, drug quantity and other information These data groups are stored in the database as standards. When the insured provides medical insurance reimbursement documents, each item of data in the medical insurance reimbursement documents is compared with the corresponding rules in the database to determine whether the medical behavior is in violation.

[0014] Such as figure 1 As shown, the rule verification system includes a rule definition unit 10 generated by a computer program, a server 11, an input unit 12, a rule verification unit 13 a...

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Abstract

The invention discloses a rule verification system for identifying violations of medical insurance reimbursement, which includes a rule definition unit, a server, an entry unit, a rule verification unit, and a verification conclusion generation unit, wherein the system maintenance personnel according to Experience input rules that can identify illegal medical insurance reimbursement behaviors, and store the rule data list and the threshold value of each rule data in the database as the basis for rule verification. During the rule verification process, the rule verification unit calculates in turn The deviation value between each data in the medical insurance settlement list and the corresponding threshold value, the verification conclusion generation unit judges that the medical insurance reimbursement behavior belongs to refusal, suspicious or normal according to the deviation value of each data, so as to automatically judge whether the medical insurance reimbursement behavior is valid or illegal .

Description

technical field [0001] The invention relates to an automatic verification system and method for medical insurance settlement documents, in particular to a rule verification system and a verification method for identifying violations 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 ...

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Application Information

Patent Timeline
06 Feb 2018
Publication
CN104182824B
IPC
G06Q10/06; G06Q50/22
Inventors
滑海蓥; 王晓霞