Claim expense early warning method and system

Abstract

The invention relates to a claim expense early warning method and system. The method comprises the following steps: step 1, extracting the medical treatment information of the customer and the expenseinformation related to each medical treatment item from the claim request of the customer; step 2, determining the international classification of diseases corresponding to the claim request of the customer according to the medical treatment information and further determining the group to which the international classification of diseases belongs; step 3, obtaining the statistical data corresponding to the group from the medical big data, wherein the statistical data include the distribution information of the treatment expense corresponding to the group; step 4, determining whether the medical treatment expense of the customer deviates from the preset range according to that distribution information and the expense information of the customer; and step 5, performing expense warning prompting if the medical treatment expense of the customer deviates from the preset range.

Description

technical field [0001] The invention relates to the technical field of insurance services based on Internet applications, in particular to a method and system for early warning of claims settlement costs. Background technique [0002] At present, there is a considerable amount of medical insurance fraud, and the existing technology lacks effective scientific identification methods for medical insurance fraud, which seriously affects the balance of medical insurance funds and infringes on the interests of the insured and the public. [0003] Health insurance is affected by disease diagnosis, medical treatment behavior, medication and diagnosis and treatment methods. There are great differences in the claims expenses of different cases, and it is difficult to establish a set of effective standards from the perspective of expenses to judge whether there is claim fraud, medical abuse and Risks such as over-medication. . [0004] Therefore, in order to suppress the above-mentio...

AI Technical Summary

Problems solved by technology

[0002] At present, there are a considerable amount of medical insurance fraud, and the existing technology lacks effective scientific identification methods for medical insurance fraud, which seriously affects the balance of income and expenditure of the medical insurance fund, and violates the interests of the majority of insured people and even the public interest

[0003] Health insurance is affected by disease diagnosis, doctor-seeking behavior, medication and diagnosis and treatment methods, and there are great differences in the claims costs of different cases, and it is difficult to establish a set of effective standards from the perspective of costs to judge whether there is claim fraud, medical abuse and Risks such as over-medication

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