Method and a system for automatically auditing the whole process of medical insurance settlement

Abstract

The invention provides a method and a system for automatically auditing the whole process of medical insurance settlement. The auditing method comprises: constructing an audit engine unit, a pre-auditunit, a in-process audit unit and a post-audit unit. The audit engine unit comprises a standardization module, a rule audit module and an anti-fraud module. Prior Audit Module, both the in-process audit unit and the post-process audit unit exchange information with the audit engine unit, The audit engine unit performs rule audit on the original medical data, performs rule audit on the data approved in advance, performs rule audit and anti-fraud calculation on the data approved in the process, and obtains the medical insurance settlement audit result for the medical insurance original data andsettlement document data approved after the review. By constructing the audit engine unit, the pre-audit unit, the in-process audit unit and the post-audit unit, the application can cover the whole medical service process as a whole, and truly achieve the pre-alert, the in-process control and the post-audit.

Description

technical field [0001] This application belongs to the technical field of medical insurance management, and specifically relates to a method and system for automatic review of the whole process of medical insurance settlement. Background technique [0002] With the continuous growth of the social economy, the level of medical services in my country has also been significantly improved, and medical insurance expenditures are showing an upward trend year by year. While the medical insurance work has achieved a lot of achievements, it is also facing the huge pressure of the medical insurance settlement audit work. In order to cope with the huge medical insurance settlement review work, standardize the medical behavior of the hospital, fundamentally guarantee the legitimate rights and interests of the insured, and realize the balance and security of the medical insurance fund, it is necessary to improve the current medical insurance fee review work and innovation. [0003] In ...

AI Technical Summary

Problems solved by technology

This audit method is mainly based on rules, and there is nothing to do about violations and frauds outside the rules. It lacks anti-fraud logic for cross-identification in multi-dimensional big data, so that the detection results of the pure rule audit method are limited and cannot be changed. Good protection against the risks of Medicare fund use

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