Risk control method for deducing illegal behavior of medical insurance through data analysis

A technology of medical insurance and data analysis, applied in the direction of medical care resources or facilities, data processing applications, patient-specific data, etc., can solve the problems of inappropriate multi-scenario, abuse, waste, etc., and achieve the effect of improving flexibility and adaptability

Active Publication Date: 2018-09-04
深圳平安医疗健康科技服务有限公司
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Problems solved by technology

However, most of the existing medical insurance risk control schemes are based on setting threshold red lines to monitor violations such as fraud, waste, and abuse. Since violations often change with medical insur

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  • Risk control method for deducing illegal behavior of medical insurance through data analysis
  • Risk control method for deducing illegal behavior of medical insurance through data analysis
  • Risk control method for deducing illegal behavior of medical insurance through data analysis

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Embodiment Construction

[0016] Below, the implementation of the technical solution will be further described in detail in conjunction with the accompanying drawings.

[0017] Those skilled in the art can understand that although the following description involves many technical details related to the embodiments of the present invention, this is only an example for illustrating the principle of the present invention, and does not imply any limitation. The present invention can be applied to occasions other than the technical details enumerated below, as long as they do not deviate from the principle and spirit of the present invention.

[0018] In addition, in order to avoid making the description in this specification redundant, in the description in this specification, some technical details that can be obtained in the existing technical documents may be omitted, simplified, modified, etc. understandable to human beings, and this does not affect the adequacy of the disclosure of this specification....

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Abstract

The invention relates to a risk control method for deducing an illegal behavior of medical insurance through data analysis, and the method comprises the steps: 1, obtaining the current and historicalclinical consultation behavior data of a risk control object and the personal information and public data correlated with the risk control object; 2, obtaining the features correlated with the clinical consultation behavior of the risk control object from the data obtained at step 1; 3, classifying the clinical consultation behavior of each clinical consultation in the current and historical clinical consultation behaviors of the risk control object into a corresponding clinical consultation class according to the extracted features, and forming a clinical consultation class sequence; 4, taking the clinical consultation class sequence formed at step 3 as an observation sequence, taking a clinical consultation purpose as a hidden state, calculating the most possible hidden state sequence according to a hidden Markov model, wherein the most possible hidden state sequence comprises the most possible clinical consultation purpose of the risk control object; 5, outputting the medical data correlated with the current and historical clinical consultation behaviors of the risk control object if the most possible clinical consultation purpose, in the hidden state sequence, of the risk control object is corresponding to an abnormal purpose.

Description

technical field [0001] The present invention relates to the technical field of Internet data processing, in particular to a risk control method that infers medical insurance violations through data analysis and provides a basis for system audit or manual audit. Background technique [0002] In the medical insurance social system, tens of thousands of outpatient and hospital medical transaction data occur every day, mainly including transactions between patients and medical institutions, and transactions between medical institutions and insurance institutions. At present, the existing medical insurance processing system is difficult to accurately identify the real needs of patients when processing payment transactions, and the insured person or medical institution may seek improper benefits from it. The existence of medical fraud has seriously affected the balance of income and expenditure of the medical insurance fund, and violated the interests of the insured and social wel...

Claims

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Application Information

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IPC IPC(8): G06Q40/08G16H40/20
CPCG06Q40/08G16H40/20G16H10/60G16H50/20
Inventor 程吉安
Owner 深圳平安医疗健康科技服务有限公司
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