Medical insurance intelligent audit method and system

Abstract

The present invention relates to a medical insurance intelligent audit method. The method comprises the following steps: creating a rule base according to at least one violation determination rule; obtaining a medication instruction of a doctor, querying a drug product mapping relationship table, a medical treatment project mapping relationship table and / or a medical supplies mapping relationship table, and generating the prescription for medication; and matching in the rule base according to standard information in the prescription for medication, obtaining at least one target violation determination rule, and using the target violation determination rule to audit whether the prescription for the medication is correct. According to the technical scheme of the present invention, the effect of the medical intelligent audit monitoring can be improved, the phenomena of over-diagnosis and treatment, indiscriminate use of drugs, arbitrary charges, and the like can be avoided, service quality of hospitals can be improved, a harmonious relationship between doctors and patients can be improved, and a win-win situation for the economic and social benefits of the hospitals can be achieved.

Description

technical field [0001] The invention relates to the field of medical data, in particular to a medical insurance intelligent audit method and system. Background technique [0002] In reality, hundreds of millions of patients go to the hospital every day. Correspondingly, doctors will issue a large number of prescriptions. Among them, there are also many unreasonable prescriptions. The unreasonableness is mainly reflected in the violation of the rational drug use guidelines. Violation of the corresponding drug management system of the health department and violation of the existing medical insurance policy, such as excessive drug use, repeated drug use, incompatibility, abuse of antibiotics, drug use beyond the doctor's level, and drug use beyond the scope of gender, etc. These unreasonable prescriptions will be punished. The patient's health will be seriously affected and the cost of medical treatment will be increased. Therefore, the medical intelligent audit monitoring syst...

AI Technical Summary

Problems solved by technology

[0002] In reality, hundreds of millions of patients go to the hospital every day. Correspondingly, doctors will issue a large number of prescriptions. Among them, there are also many unreasonable prescriptions. The unreasonableness is mainly reflected in the violation of the rational drug use guidelines. Violation of the corresponding drug management system of the health department and violation of the existing medical insurance policy, such as excessive drug use, repeated drug use, incompatibility, abuse of antibiotics, drug use beyond the doctor's level, and drug use beyond the scope of gender, etc. These unreasonable prescriptions will be punished. The patient's health will be seriously affected and the cost of medical treatment will be increased. Therefore, the medical intelligent audit monitoring system is required to monitor and audit the hospital's prescription and medical settlement data

At present, the medical intelligent audit monitoring system on the market is generally configured through a rule engine, and then analyzes the settlement data of medical treatment, promotes the supervision of hospitals, and increases punishment for medical violations and fraud. There are differences in medicines, so that there will be errors in the medical intelligent audit monitoring system, and it is impossible to accurately confirm whether the prescription issued by the doctor is in violation of regulations

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