Detection method and system of health insurance compensation fraud and abuse

Abstract

The embodiment of the invention discloses a detection method and system of health insurance compensation fraud and abuse. The method includes: receiving a claim application submitted by user equipment; acquiring data, which are required for a claim, according to the claim application; according to the data required for the claim, judging whether a pre-established model scoring engine and rule scoring engine are called; If yes, calling the model scoring engine on the basis of the data, which are required for the claim, to generate a model score and a risk prompting factor, and calling the rulescoring engine to generate rule triggering results and rule risk scores; generating a risk evaluation report according to the generated model score, risk prompting factor, rule triggering results andrule risk scores; and according to the risk evaluation report, obtaining a conclusion of whether the claim is finally settled, and storing claim data of the obtained claim conclusion into a historicalclaim database. According to the embodiment of the invention, detection on health insurance compensation fraud and abuse can be realized, and accuracy and efficiency of detection are greatly improved.

Description

technical field [0001] The embodiments of the present invention relate to the technical field of data processing, and in particular to a method and system for detecting fraud and abuse of health insurance claims. Background technique [0002] As commercial health insurance is accepted by more and more people in my country, insurance has become an important channel for individuals and families to provide medical security. However, insurance fraud not only damages the interests of insurance institutions, but also damages the interests of the majority of policyholders. Statistics show that the amount of international insurance fraud accounts for about 10% of the total compensation, and the amount of fraud in some insurance types even accounts for as much as 50%. The American Health Anti-Fraud Association estimates that health fraud is at least $68 billion a year, and other agencies estimate that the amount of fraud is as high as $230 billion a year. [0003] Health and medica...

AI Technical Summary

Problems solved by technology

However, due to the various forms of insurance fraud, manual verification is difficult, and pain points such as discovery and identification lags pose challenges for the establishment of large-scale anti-fraud systems.

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