Risk control method for inferring medical insurance violations through data analysis
A technology for medical insurance and data analysis, applied in the direction of medical care resources or facilities, data processing applications, patient-specific data, etc., can solve problems such as being unsuitable for multiple scenarios, waste, abuse, etc., and achieve the effect of improving flexibility and adaptability
Active Publication Date: 2020-11-10
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 insurance policies, payment methods, and supervision, simple threshold divisions are not suitable. The actual application environment of multiple scenarios, the composition of insured personnel, and policy replacement
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[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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The present application relates to a risk control method for determining irregular medical insurance behavior by means of data analysis. The method comprises: step 1: acquiring current and historical medical treatment behavior data of a person under risk control and personal information and public data related to the person under risk control; step 2: extracting, from the data acquired in step 1, features related to medical treatment behavior of the person under risk control; step 3: classifying, according to the extracted features, each medical treatment behavior of the current and historical medical treatment behavior of the person under risk control into corresponding medical treatment categories, so as to generate a medical treatment category sequence; step 4: using the medical treatment category sequence generated in step 3 as an observation sequence, using a medical treatment purpose as a hidden state, and calculating, according to a Hidden Markov model, a most likely hidden state sequence which comprises a most likely medical treatment purpose; and step 5: if the most likely medical treatment purpose of the person under risk control comprised in the hidden state sequence corresponds to an abnormal purpose, outputting medical data related to the current and historical medical treatment behavior of the person under risk control.
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...
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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