Medical insurance illegal behavior monitoring system and auditing method

Abstract

The invention discloses a medical insurance illegal behavior monitoring system and auditing method, and the system comprises a data storage library and an auditing system, the data storage library is in butt joint with the auditing system through the Ethernet, the auditing system is in butt joint with an import unit, and the import unit is used for importing the treatment information of a patient into the auditing system.The invention relates to the technical field of medical insurance auditing. According to the medical insurance violation behavior monitoring system and the auditing method, cases having medical insurance reimbursement conditions under different disease types are integrated, medical insurance part identification processing is carried out on the cases, the cases are filled into a framework modeling unit to serve as reimbursement comparison cases, and when a patient needs medical insurance reimbursement, the medical insurance part identification processing is carried out on the cases; according to the method, the medical insurance reimbursement comparison cases are subjected to conventional comparison with the same type of reimbursement comparison cases, conventional medical insurance reimbursement parts are effectively screened out, and the screened different parts are subjected to key auditing, so that the workload of workers is effectively reduced, and the quality of medical insurance violation auditing can be effectively improved due to the fact that the key auditing parts are few.

Description

technical field [0001] The invention relates to the technical field of medical insurance auditing, in particular to a medical insurance violation monitoring system and an auditing method. Background technique [0002] Social medical insurance is a social insurance system established by the state and society in accordance with certain laws and regulations to provide basic medical needs protection for workers within the scope of protection when they are sick. It is undertaken by the government and enforced by means of economic, administrative and legal means. It is also organized and managed. Social medical insurance consists of three levels: basic medical insurance and large-amount medical assistance, corporate supplementary medical insurance, and individual supplementary medical insurance. [0003] In the process of popularizing medical insurance, a large number of violations have occurred, such as the declaration of settlement indicators does not match the condition; the us...

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Problems solved by technology

[0003] In the process of popularizing medical insurance, a large number of violations have occurred, such as the declaration of settlement indicators does not match the condition; the use of non-listed drugs, inspection and treatment items without the consent of the insured or their family members; The treatment item is not implemented for some reason, and there is no refund; the bill of expenses, the inpatient doctor's order, the treatment order, and the course of the disease record do not match; the treatment item or inspection item is discharged from the hospital; Mon

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