Online supervision method for illegal medical insurance fund use behaviors of medical insurance fixed-point retail drugstores

Abstract

The invention relates to the technical field of medical insurance supervision, in particular to an online supervision method for illegal medical insurance fund use behaviors of a medical insurance fixed-point retail pharmacy. Comprising the following steps: importing a drugstore purchase-sale-stock commodity library into an online supervision system as commodity basic data of a drugstore in the online supervision system; the pharmacy is limited to only initiate a medical insurance order through the online supervision system when performing a sales behavior, and a medical insurance order initiation mode of the online supervision system covers all medical insurance reimbursement modes in a daily operation process of the pharmacy; in the process that a drugstore initiates an order through the online supervision system, the online supervision system calls a built-in medical insurance knowledge base and a rule base in real time to verify the opened order in real time and reminds or intercepts the content which does not conform to the medical insurance fund payment specification in real time. And reasonable and safe use of medical insurance funds is ensured.

Description

Technical Field

[0001] The present invention relates to the field of medical insurance supervision technology, and in particular to a method for online supervision of medical insurance designated retail pharmacies' illegal use of medical insurance funds. Background Art

[0002] Ensuring the safe use of medical insurance funds is crucial in the supervision of designated retail pharmacies for medical insurance. Currently, centralized cloud MIS systems are widely used in the traditional regulatory model for designated retail pharmacies. However, this solution has significant drawbacks, the most prominent of which is the inability to effectively monitor the use of medical insurance funds both before and during the process. Existing solutions only allow medical insurance supervisors to extract purchase, sales, and inventory data after medical insurance reimbursement is completed to aid on-site inspections to identify violations. However, it is difficult to intercept or alert violations online during the reimbursement process at designated retail pharmacies. This results in numerous instances of illegal use of medical insurance funds being discovered only after they occur, exposing medical insurance funds to significant losses and resulting in high costs for subsequent tracing and resolution. With the continued expansion of medical insurance fund usage and the increasing complexity of usage scenarios, this issue is becoming increasingly complex.

[0003] There is an urgent need for a technical solution that can intervene in the process of medical insurance fund use in pharmacies and conduct online real-time supervision, move the supervision checkpoint forward, prevent violations at the source, and ensure the rational and safe use of medical insurance funds. Summary of the Invention

[0004] The purpose of the present invention is to address the shortcomings of the existing technology and propose a method for online supervision of the illegal use of medical insurance funds by designated medical insurance retail pharmacies, including: Importing the pharmacy's inventory database into the online supervision system as the pharmacy's commodity basic data in the online supervision system; Pharmacies are restricted to initiating medical insurance orders only through the online supervision system when making sales. The initiation of medical insurance orders through the online supervision system covers all medical insurance reimbursement methods in the daily operation of pharmacies; When a pharmacy places an order through the online supervision system, the online supervision system calls the built-in medical insurance knowledge base and rule base in real time to verify the order, and issues a real-time reminder or intercepts any content that does not comply with the medical insurance fund payment regulations; The online supervision system generates an order information QR code based on the medical insurance order, and the order information QR code is transmitted between related systems. The pharmacy staff completes the price marking, reimbursement and fee information receipt work in sequence based on the order information QR code; The online supervision system synchronously transmits the pharmacy order data to the medical insurance department, realizing the control of the source of billing, the process of billing, the result of charging and the integration of full data.

[0005] Preferably, the importing of the pharmacy's purchase, sales and inventory commodity library into the online supervision system includes: obtaining commodity information in the pharmacy's purchase, sales and inventory commodity library, the commodity information at least including commodity name, specifications, manufacturer, price, and inventory quantity; performing format conversion and standardization on the commodity information to make it conform to the data format requirements of the online supervision system; importing the processed commodity information into the online supervision system, and establishing a unique correspondence with the actual commodities of the pharmacy.

[0006] Further preferably, the medical insurance order initiation methods of the online supervision system cover all medical insurance reimbursement methods in the daily operation of the pharmacy, specifically including: supporting the initiation of medical insurance orders for counter sales, supporting the initiation of medical insurance orders for online drug purchases, and supporting the initiation of medical insurance orders for external prescriptions at designated medical institutions; and each medical insurance order initiation method requires the completion of order information entry, review and submission operations in the online supervision system.

[0007] Further preferably, the medical insurance knowledge base includes at least a medical insurance drug catalog, a medical insurance diagnosis and treatment item catalog, and medical insurance service facility standards; the rule base includes at least medical insurance fund payment rules, medical insurance reimbursement ratio rules, and medical insurance drug dosage rules; when the online supervision system calls the medical insurance knowledge base and rule base to perform real-time verification of the orders placed, the verification is performed in sequence according to the preset verification priority order.

[0008] Further preferably, when performing real-time verification on the order placed, the amount payable by the medical insurance fund is calculated based on the following formula: ; in, Indicates the amount that can be paid by the medical insurance fund; Indicates the types and quantities of goods or services in the order; Indicates the order the quantity of the good or service; Indicates the order The unit price of a good or service; Indicates the order The medical insurance reimbursement ratio corresponding to the goods or services, ; Indicates the order The medical insurance payment status mark of the commodity or service When the goods or services meet the medical insurance payment requirements ,otherwise .

[0009] Further preferably, when the verification finds that the order contains content that does not comply with the medical insurance fund payment regulations, the violation risk coefficient is calculated based on the following formula: ; in, represents the violation risk coefficient, ; Indicates the types and quantity of goods or services in the order that do not comply with the medical insurance fund payment regulations; Indicates that the order does not comply with the medical insurance fund payment regulations. the quantity of the good or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The unit price of a good or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The medical insurance reimbursement ratio corresponding to the commodity or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The medical insurance payment status mark of the commodity or service When a product or service does not meet the medical insurance payment regulations ; Indicates the types and quantities of goods or services in the order; Indicates the order the quantity of the good or service; Indicates the order The unit price of a good or service; When the preset threshold is exceeded, the online supervision system performs real-time interception.

[0010] Further preferably, when the online supervision system performs real-time verification on the order, it also evaluates the overall compliance of the order based on the following formula: ; in, Indicates the overall compliance coefficient of the order, ; Indicates the number of prescription-related verification items involved in the order; Indicates the The weight of each prescription-related verification item, ,and ; Indicates the The compliance status mark of each prescription-related verification item, when the When the relevant verification items of each prescription meet the requirements ,otherwise ; and Respectively represent the compliance weight of medical insurance fund payment and prescription compliance weight, ,and 、 .

[0011] Further preferably, the order information QR code includes the order number, pharmacy logo, insured person information, product or service information, and medical insurance fund payment information; the associated system includes the pharmacy cashier system, medical insurance settlement system, and medical insurance supervision system; when the order information QR code is transmitted between associated systems, it is encrypted using an encryption algorithm to ensure data transmission security.

[0012] Further preferably, after the online supervision system synchronously transmits the pharmacy order data to the medical insurance department, it also stores and analyzes the order data, specifically including: classifying and storing the order data according to preset time periods; performing statistical analysis on the order data based on big data analysis technology, generating medical insurance fund usage reports and violation analysis reports; and feeding back the analysis results to the medical insurance department to provide data support for medical insurance policy adjustments and regulatory decisions.

[0013] Further preferably, the online supervision system supports docking with Internet medical institutions that meet the medical insurance management requirements, receives follow-up prescriptions issued by Internet medical institutions, and performs compliance verification on the follow-up prescriptions; when the follow-up prescription passes the verification, a medical insurance order is initiated in the online supervision system based on the follow-up prescription.

[0014] Technical effect: The technical solution provided by the present invention effectively solves the problem of the inability to supervise medical insurance funds in advance and during the process in the background technology. Its creativity lies in the construction of a unified sales portal and data closed-loop supervision model. Pharmacies can only initiate medical insurance orders through the online supervision system. The system calls the knowledge base and rule base for verification in real time, and reminds or intercepts violations in real time. At the same time, it realizes the full process control of ordering and data integration and transmission, which not only moves the supervision checkpoint forward, prevents and controls violations in a timely manner during the reimbursement process, reduces fund losses, and reduces interference with pharmacy operations. It ensures the safety of medical insurance funds while taking into account the operational needs of pharmacies, significantly improving supervision efficiency and quality. BRIEF DESCRIPTION OF THE DRAWINGS

[0015] Figure 1 This is a flow chart of the method for online supervision of illegal use of medical insurance funds by designated retail pharmacies for medical insurance application. DETAILED DESCRIPTION

[0016] In order to make the purpose, technical solutions and advantages of the present invention more clearly understood, the present invention will be further described in detail below with reference to the accompanying drawings and embodiments. It should be understood that the specific embodiments described herein are only used to explain the present invention and are not intended to limit the present invention.

[0017] See also Figure 1, for example, traditional technical solutions have the following technical problems: the existing centralized cloud MIS system solution has many problems, such as interference with pharmacy operations, especially cross-regional chain pharmacies; inability to verify prescription compliance and effectively control reimbursement behaviors that do not comply with regulations; inability to access convenient follow-up prescription services; and only able to extract data for auxiliary inspection afterwards, unable to implement online interception or reminder of violations during the reimbursement process. Based on this, this embodiment proposes a method for online supervision of the illegal use of medical insurance funds by designated medical insurance retail pharmacies, including: Importing the pharmacy's inventory database into the online supervision system as the pharmacy's commodity basic data in the online supervision system; Pharmacies are restricted to initiating medical insurance orders only through the online supervision system when making sales. The initiation of medical insurance orders through the online supervision system covers all medical insurance reimbursement methods in the daily operation of pharmacies; When a pharmacy places an order through the online supervision system, the online supervision system calls the built-in medical insurance knowledge base and rule base in real time to verify the order, and issues a real-time reminder or intercepts any content that does not comply with the medical insurance fund payment regulations; The online supervision system generates an order information QR code based on the medical insurance order, and the order information QR code is transmitted between related systems. The pharmacy staff completes the price marking, reimbursement and fee information receipt work in sequence based on the order information QR code; The online supervision system synchronously transmits the pharmacy order data to the medical insurance department, realizing the control of the source of billing, the process of billing, the result of charging and the integration of full data.

[0018] It is worth mentioning that: this embodiment has constructed the core framework of the online supervision method for the illegal use of medical insurance funds by designated medical insurance retail pharmacies. First, the pharmacy's inventory and purchase goods database is imported into the online supervision system to provide basic data for subsequent supervision; then, the pharmacy's sales behavior is limited to initiating medical insurance orders only through this system, realizing the unification of sales entrances; in the order initiation process, the medical insurance knowledge base and rule base are called in real time for verification, and illegal content is reminded or intercepted; by generating an order information QR code and transmitting it in the associated system, the pricing, reimbursement and other processes are completed; finally, the order data is synchronously transmitted to the medical insurance department to achieve control over the source, process, and results of the order and the integration of all data. The entire process forms a closed loop to ensure the standardization and controllability of the use of medical insurance funds.

[0019] The technical effects achieved by the above embodiments include: reducing interference with pharmacy operations by unifying sales portals and data centralization, especially for pharmacies with their own chain-based centralized cloud MIS systems, without having to change their internal management systems, thus reducing operating costs. Pre-emptive and in-process supervision of the use of medical insurance funds is achieved. Compared with the post-supervision of existing solutions, violations can be discovered and prevented in a timely manner, effectively reducing the economic losses of pharmacies due to medical insurance violations. By supervising prescriptions and connecting to convenient follow-up prescription services, the convenience of medical treatment for insured people is improved, while the security of medical insurance funds is fully guaranteed, and the efficiency and accuracy of medical insurance supervision are achieved.

[0020] For example, the traditional technical solution has the following technical problems: Since the data formats of the purchase, sales and inventory product libraries of different pharmacies may be different, if they are directly imported into the online supervision system, it may cause problems such as data unrecognition, incorrect reading or information confusion, affecting the normal operation of the supervision system and the accuracy of supervision. In addition, if an accurate commodity correspondence cannot be established, misjudgment or omission may occur during the order verification process, and the use of medical insurance funds cannot be effectively supervised. Based on this, the importation of the pharmacy's purchase, sales and inventory product library into the online supervision system includes: obtaining commodity information in the pharmacy's purchase, sales and inventory product library, the commodity information at least includes commodity name, specifications, manufacturer, price, and inventory quantity; performing format conversion and standardization on the commodity information to make it conform to the data format requirements of the online supervision system; importing the processed commodity information into the online supervision system, and establishing a unique correspondence with the actual commodity of the pharmacy.

[0021] This embodiment solves the data compatibility and accuracy issues by standardizing the data import process.

[0022] It is worth mentioning that this embodiment further refines the aforementioned operational process for importing a pharmacy's inventory database into an online supervision system. First, product information from the pharmacy's inventory database is obtained, including key information such as product name, specifications, manufacturer, price, and inventory quantity. This information is then formatted and standardized to conform to the data format requirements of the online supervision system, ensuring data consistency and compatibility. Finally, the processed product information is imported into the system and a unique correspondence is established with the pharmacy's actual products, providing an accurate data foundation for subsequent order verification and supervision.

[0023] The technical effects achieved by the above embodiments include: after format conversion and standardization, the online supervision system can accurately read and process the product information of the pharmacy, avoiding system failures or data errors caused by data format problems. The establishment of a unique correspondence ensures that when verifying an order, the system can accurately match the product information with the medical insurance regulations, thereby improving the accuracy and reliability of the verification. This enables the supervision system to more accurately determine whether the order complies with the medical insurance fund payment regulations, effectively reducing misjudgments and omissions, further ensuring the security of the medical insurance fund, and also providing accurate data support for pharmacies and medical insurance departments, facilitating subsequent data analysis and decision-making.

[0024] For example, traditional technical solutions have the following technical problems: With the diversification of pharmacy business models, medical insurance reimbursement methods are becoming increasingly complex. If various medical insurance order initiation methods are not fully covered, there may be regulatory loopholes, and some medical insurance fund usage behaviors cannot be effectively supervised. At the same time, the lack of a unified order initiation operation process may lead to problems such as non-standard order information and inconsistent review standards under different methods, affecting the efficiency and accuracy of medical insurance fund supervision. Based on this, the medical insurance order initiation methods of the online supervision system cover all medical insurance reimbursement methods in the daily operation of pharmacies, specifically including: supporting the initiation of medical insurance orders for counter sales, supporting the initiation of medical insurance orders for online drug purchases, and supporting the initiation of medical insurance orders for prescriptions from designated medical institutions; and each medical insurance order initiation method requires the completion of order information entry, review, and submission operations in the online supervision system.

[0025] It's worth noting that this embodiment specifies that the online supervision system's medical insurance order initiation methods cover all daily pharmacy reimbursement methods, including over-the-counter sales, online drug purchases, and prescription dispensing at designated medical institutions. Furthermore, each initiation method requires the system to complete order information entry, review, and submission. This ensures that all medical insurance order initiations are conducted under a unified supervision process, enabling effective oversight regardless of the sales scenario.

[0026] The technical effects achieved by the above embodiments include: comprehensive coverage of various medical insurance order initiation methods, ensuring that every link in the use of medical insurance funds is under supervision, eliminating regulatory blind spots, and effectively preventing violations from evading supervision through special sales scenarios. The unified order initiation operation process ensures the standardization of order information and the consistency of audit standards, and improves the efficiency and accuracy of the supervision system in processing orders. This enables the medical insurance department to have a more comprehensive and accurate understanding of the use of medical insurance funds, and to promptly discover and deal with violations. It also facilitates pharmacies to operate in accordance with unified standards and reduce the risks caused by non-standard operations.

[0027] For example, traditional technical solutions have the following technical problems: medical insurance policies and regulations involve many aspects and are relatively complex. Without a clear knowledge base and rule base, it is difficult for the supervision system to accurately determine whether the order complies with the medical insurance fund payment regulations. In addition, if the verification process has no priority order, it may lead to low verification efficiency and even the neglect of important issues. Based on this, the medical insurance knowledge base at least includes the medical insurance drug catalog, the medical insurance diagnosis and treatment item catalog, and the medical insurance service facility standards; the rule base at least includes the medical insurance fund payment rules, the medical insurance reimbursement ratio rules, and the medical insurance drug dosage rules; when the online supervision system calls the medical insurance knowledge base and rule base to perform real-time verification of the orders placed, it performs verification in sequence according to the preset verification priority order.

[0028] It's worth noting that this embodiment details the contents of the medical insurance knowledge base and rule base. The knowledge base includes the medical insurance drug catalog, the medical insurance diagnosis and treatment item catalog, and medical insurance service facility standards. The rule base includes medical insurance fund payment rules, medical insurance reimbursement ratio rules, and medical insurance medication dosage rules. It also stipulates that when the online supervision system calls these libraries to perform real-time order verification, it performs verification in sequence according to a preset verification priority order to ensure the scientific and orderly verification process.

[0029] The technical effects achieved by the above embodiments include: a clear and specific medical insurance knowledge base and rule base provide an accurate verification basis for the online supervision system, enabling the system to accurately judge orders based on medical insurance policies and regulations, thereby improving the accuracy and standardization of supervision. The preset verification priority order ensures that when processing orders, the system can prioritize key and important verification items, improving verification efficiency and promptly identifying and addressing potential violations. This avoids the failure to promptly detect violations due to verification confusion or omission of important items, further ensuring the safe and reasonable use of medical insurance funds.

[0030] For example, traditional technical solutions have the following technical problems: During the payment process of medical insurance funds, traditional calculation methods may not be accurate enough, which can easily lead to overpayment or underpayment, resulting in irrational use of medical insurance funds. Moreover, the lack of a scientific calculation formula makes it difficult to fully consider the impact of various factors in the order on the payment of medical insurance funds, and it is impossible to accurately judge the rationality of medical insurance fund payments. Based on this, when performing real-time verification of the orders opened, the amount payable by the medical insurance fund is calculated based on the following formula: ; in, Indicates the amount that can be paid by the medical insurance fund; Indicates the types and quantities of goods or services in the order; Indicates the order the quantity of the good or service; Indicates the order The unit price of a good or service; Indicates the order The medical insurance reimbursement ratio corresponding to the goods or services, ; Indicates the order The medical insurance payment status mark of the commodity or service When the goods or services meet the medical insurance payment requirements ,otherwise .

[0031] In the technical solution for online supervision of illegal use of medical insurance funds by designated retail pharmacies, this formula is used to calculate the amount that can be paid by the medical insurance fund. Among them, Indicates the number of types of goods or services in an order. It is a basic parameter that defines the scope of calculation and clarifies how many different goods or services in the order should be comprehensively considered. For example, if a medical insurance order contains three products: cold medicine, fever-reducing medicine, and band-aids, then The value of . Represents the order The quantity of a commodity or service, which reflects the actual transaction quantity of each specific commodity or service in the order. For example, in the above order, the cold medicine purchased box, then for the product of cold medicine, (Assume that cold medicine is The quantity of a commodity directly affects the amount of medical insurance fund payment corresponding to the commodity. It is the first The unit price of a commodity or service is one of the key factors in calculating the total price of a commodity or service. The unit price of different commodities or services varies greatly, and it is closely related to the quantity. Multiply them together to get the original price of each commodity or service without considering medical insurance reimbursement. For example, the price of a box of cold medicine is Yuan, that is Yuan. Indicates the order The medical insurance reimbursement ratio corresponding to the goods or services, This parameter reflects the degree of support for reimbursement of different commodities or services by the medical insurance policy. For example, the reimbursement ratio of a certain drug is , which means that the cost of the drug It can be paid by the medical insurance fund. The value of depends on the medical insurance policy and the attributes of the product or service itself. For the order The medical insurance payment status mark of the commodity or service When the goods or services meet the medical insurance payment requirements ,otherwise It plays a role of screening and filtering. Only goods or services that meet the medical insurance payment conditions will be included in the calculation of the amount that can be paid by the medical insurance fund. For example, if a health product is not within the scope of medical insurance payment, then for this health product, The corresponding expenses will not be included in the calculation of the amount payable by the medical insurance fund. The entire formula performs a comprehensive calculation on the quantity, unit price, medical insurance reimbursement ratio and payment status of each commodity or service in the order, and accumulates the corresponding payable amounts of commodities or services that meet the medical insurance payment regulations to obtain the final amount payable by the medical insurance fund for the order. This calculation method comprehensively and accurately considers all key factors that affect the payment of medical insurance funds. Compared with the traditional simple estimation method, it can more accurately determine the actual amount that the medical insurance fund should pay, effectively avoiding the situation of overpayment or underpayment of the medical insurance fund, and providing a scientific calculation basis for the rational use and precise supervision of the medical insurance fund.

[0032] It is worth mentioning that: when performing real-time verification of orders, this embodiment introduces the formula Calculate the amount that can be paid by the medical insurance fund. Indicates the amount that can be paid by the medical insurance fund. Indicates the types and quantities of goods or services in the order. Indicates the the quantity of goods or services, Indicates the The unit price of a good or service, Indicates the The medical insurance reimbursement ratio corresponding to the goods or services, Indicates the This formula comprehensively considers all key factors of the goods or services in the order and accurately calculates the amount that can be paid by the medical insurance fund.

[0033] The technical effects achieved by the above embodiment include: the formula comprehensively considers key factors such as the quantity, unit price, reimbursement ratio, and payment status of goods or services in an order, and can accurately calculate the amount payable by the medical insurance fund. Compared with traditional calculation methods, this greatly improves calculation accuracy, avoids unreasonable payments from the medical insurance fund, and effectively ensures the rational use and security of the medical insurance fund. At the same time, it provides medical insurance departments and pharmacies with a clear and scientific basis for calculating payment amounts, facilitating the verification and management of medical insurance fund payments by both parties and reducing disputes and violations arising from payment amount calculation issues.

[0034] For example, traditional technical solutions have the following technical problems: they only determine whether there is content in the order that does not comply with the medical insurance fund payment regulations, but cannot accurately assess the severity and risk of the violation, making it difficult to determine whether immediate interception measures are needed. Moreover, due to the lack of quantitative violation risk assessment standards, different supervisors may handle violations differently, affecting the consistency and effectiveness of supervision. Based on this, when the verification finds that there is content in the order that does not comply with the medical insurance fund payment regulations, the violation risk coefficient is calculated based on the following formula: ; in, represents the violation risk coefficient, ; Indicates the types and quantity of goods or services in the order that do not comply with the medical insurance fund payment regulations; Indicates that the order does not comply with the medical insurance fund payment regulations. the quantity of the good or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The unit price of a good or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The medical insurance reimbursement ratio corresponding to the commodity or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The medical insurance payment status mark of the commodity or service When a product or service does not meet the medical insurance payment regulations ; Indicates the types and quantities of goods or services in the order; Indicates the order the quantity of the good or service; Indicates the order The unit price of a good or service; When the preset threshold is exceeded, the online supervision system performs real-time interception.

[0035] This formula is used to calculate the violation risk factor In the process of medical insurance fund supervision, it helps to judge the risk level of violation when there is a violation of the provisions of medical insurance fund payment in the order. Indicates the number of goods or services in the order that do not comply with regulations. It clarifies the types and scope of goods or services suspected of violating regulations in the order. For example, if there are two goods in an order that do not comply with medical insurance payment regulations, then . 、 、 、 They correspond to the quantity, unit price, reimbursement ratio and payment status identification of goods or services that do not comply with regulations. Their meanings are similar to the corresponding parameters in the formula for the amount payable by the medical insurance fund, but the focus here is on the parts that do not comply with regulations. This reflects the actual number of transactions of the illegal goods or services. The larger the number, the greater the potential impact of the illegal amount. The unit price of the illegal goods or services. The higher the unit price, the higher the risk of violation. In this item, Originally it was the reimbursement ratio. It emphasizes the proportion of the part that is not reimbursed according to regulations in the case of violations, such as the normal reimbursement ratio is If the violation , indicating that there is There is a risk of non-compliance with the fees; In, because Indicates the payment status indicator. When it does not meet the requirements ,so , ensuring that only the parts that do not comply with regulations are included in the violation risk calculation. , is the sum of the quantity, unit price, violation ratio and violation mark of all non-compliant goods or services, and the total potential risk amount of the non-compliant part of the order is obtained. Represents the original total amount of all goods or services in the entire order (excluding medical insurance reimbursement and violations). The violation risk coefficient is calculated by the ratio of the numerator to the denominator. , . The closer the value , indicating that the greater the proportion of the illegal part of the order to the total order amount, the higher the risk of violation; The closer the value , the lower the risk of violation. When the preset threshold is exceeded, the online supervision system will conduct real-time interception. This quantitative violation risk assessment method enables the supervision system to judge the violation risk level of the order more objectively and accurately, avoiding the subjectivity and uncertainty of human judgment, and realizing accurate identification and timely intervention of violations, effectively ensuring the security of medical insurance funds and preventing medical insurance funds from suffering losses due to violations.

[0036] It is worth mentioning that: based on the above embodiment, when the verification finds that there are contents in the order that do not comply with the medical insurance fund payment regulations, the formula Calculate the violation risk coefficient. represents the violation risk coefficient, Indicates the number of types of goods or services that do not comply with regulations. 、 、 、 The corresponding quantities, unit prices, reimbursement ratios and payment status indicators of non-compliant goods or services, 、 、 The meaning is the same as the calculation formula of the amount payable by the medical insurance fund. When the pre-set threshold is exceeded, the online monitoring system conducts real-time interception. This formula quantifies the risk of violations and enables timely intervention in violations.

[0037] The technical effects achieved by the above embodiment include: the formula quantifies the various factors that do not conform to regulations in an order to produce an accurate violation risk coefficient, which can intuitively reflect the severity and risk of the violation. When the violation risk coefficient exceeds the preset threshold, the system automatically intercepts it in real time, achieving precise intervention in the violation and preventing further losses caused by the violation. At the same time, the unified violation risk assessment standard ensures the consistency and fairness of supervision, improves the efficiency and authority of supervision, effectively protects the security of medical insurance funds, and reduces illegal expenditures of medical insurance funds.

[0038] For example, traditional technical solutions have the following technical problems: the previous verification method mainly focuses on medical insurance fund payments, and does not give sufficient comprehensive consideration to prescription compliance, which is also crucial for the rational use of medical insurance funds. If the compliance of an order cannot be fully assessed, some potential violation risks may be missed, leading to unreasonable expenditure of medical insurance funds. Based on this, the online supervision system also evaluates the overall compliance of the order based on the following formula when performing real-time verification of the order: ; in, Indicates the overall compliance coefficient of the order, ; Indicates the number of prescription-related verification items involved in the order; Indicates the The weight of each prescription-related verification item, ,and ; Indicates the The compliance status mark of each prescription-related verification item, when the When the relevant verification items of each prescription meet the requirements ,otherwise ; and Respectively represent the compliance weight of medical insurance fund payment and prescription compliance weight, ,and 、 .

[0039] This formula is used to evaluate the overall compliance coefficient of the order , which comprehensively considers two important aspects: medical insurance fund payment compliance and prescription compliance. In the formula, This part is related to the idea of ​​the formula for the amount payable by the medical insurance fund. The numerator is the amount payable by the medical insurance fund calculated in accordance with the medical insurance regulations, and the denominator is the original total amount of all goods or services in the order. The ratio of the two reflects the compliance level of the medical insurance fund payment part in the total amount of the order, and reflects the compliance of the order in terms of medical insurance fund payment. represents the compliance weight of medical insurance fund payment, , which is used to adjust the importance of medical insurance fund payment compliance in the overall compliance assessment of the order. For example, if the medical insurance fund payment compliance is considered more critical, the The value of makes the compliance of medical insurance fund payment have an impact on the overall compliance coefficient of the order The impact is greater. In part, Indicates the number of prescription-related verification items involved in the order. It clarifies the number of items that need to be considered in prescription compliance verification. For example, a prescription may involve multiple verification items such as drug incompatibility, rationality of drug dosage, and qualifications of the prescribing doctor. This is the total number of these check items. Indicates the The weight of each prescription-related verification item, ,and Different prescription verification items have different degrees of importance to prescription compliance, and this difference is reflected by assigning different weights. For example, drug incompatibility may be a very critical verification item and be assigned a higher weight; while prescription format specifications are relatively less important and are assigned a lower weight. Indicates the The compliance status mark of each prescription-related verification item, when the When the relevant verification items of each prescription meet the requirements ,otherwise , which is used to determine whether each prescription verification item is compliant. The weight of each prescription verification item is multiplied by the compliance status indicator and then summed to obtain the comprehensive score of prescription compliance; the denominator It is used for normalization processing so that the results of this part are within a reasonable numerical range. represents the prescription compliance weight, ,and , which adjusts the importance of prescription compliance in the overall compliance evaluation of the order. The overall compliance coefficient of the order is obtained by weighting the medical insurance fund payment compliance and prescription compliance according to their respective weights. , .when When the threshold falls below the pre-set compliance threshold, the system issues a real-time alert. This comprehensive assessment method comprehensively considers the two key factors that affect order compliance, enabling a more comprehensive and accurate assessment of whether an order complies with medical insurance regulations, promptly identifying potential non-compliance risks and avoiding the irrational use of medical insurance funds due to insufficient consideration of a single factor, further enhancing the comprehensiveness and effectiveness of medical insurance fund supervision.

[0040] It is worth mentioning that: this embodiment further improves the order verification, based on the above embodiment, using the formula Evaluate the overall compliance of the order. Indicates the overall compliance coefficient of the order, 、 、 、 、 The meaning is the same as the calculation formula of the amount payable by the medical insurance fund. Indicates the number of prescription-related verification items, Indicates the The weight of each prescription-related verification item, Indicates the The compliance status indicator of each prescription-related verification item, and Represent the compliance weight of medical insurance fund payment and prescription compliance weight respectively. When the amount falls below the preset compliance threshold, the system will issue a real-time alert. It comprehensively assesses order compliance by considering both medical insurance fund payment compliance and prescription compliance.

[0041] The technical effects achieved by the above embodiment include: This formula combines medical insurance fund payment compliance and prescription compliance, comprehensively assessing the overall compliance of an order through weighted distribution, and can more comprehensively and accurately determine whether an order complies with medical insurance regulations. When the overall compliance coefficient of an order falls below a preset threshold, the system promptly issues an alert, enabling pharmacies and medical insurance departments to promptly identify potential non-compliance risks and take appropriate measures to adjust and address them. This effectively avoids the irrational use of medical insurance funds due to factors such as non-compliant prescriptions, further strengthens the supervision of medical insurance funds, and improves the safety and rationality of their use.

[0042] For example, traditional technical solutions have the following technical problems: order information involves important information such as pharmacies, insured persons, and medical insurance funds. If the information is leaked or tampered with during the transmission process, it may lead to serious problems such as loss of medical insurance funds and leakage of insured person information. Moreover, the data interaction between different related systems needs to ensure the accuracy and consistency of information, otherwise it will affect the normal progress of medical insurance reimbursement and supervision processes. Based on this, the order information QR code contains the order number, pharmacy logo, insured person information, product or service information, and medical insurance fund payment information; the related systems include the pharmacy cash register system, medical insurance settlement system, and medical insurance supervision system; when the order information QR code is transmitted between related systems, it is encrypted using an encryption algorithm to ensure data transmission security.

[0043] It is worth mentioning that the order information QR code clearly includes key content such as the order number, pharmacy logo, insured person information, product or service information, and medical insurance fund payment information. It also points out that the connected systems include the pharmacy cashier system, medical insurance settlement system, and medical insurance supervision system. It also stipulates that the order information QR code must be encrypted using an encryption algorithm when transmitted between connected systems to ensure the security and integrity of the data during transmission.

[0044] The technical effects achieved by the above-mentioned embodiments include: specifying in detail the content contained in the order information QR code, ensuring the integrity and accuracy of data exchange between related systems, enabling each system to accurately obtain the required information and smoothly complete processes such as pricing and reimbursement. The use of an encryption algorithm to encrypt the QR code effectively prevents the theft and tampering of order information during transmission, ensuring data security, protecting the privacy of insured persons, and the security of medical insurance funds. At the same time, standardized data transmission methods improve the efficiency and reliability of medical insurance reimbursement and supervision processes, reducing process delays and errors caused by data issues.

[0045] For example, traditional technical solutions have the following technical problems: simply transmitting order data to the medical insurance department cannot fully realize the value of the data. The medical insurance department needs to conduct in-depth analysis of large amounts of order data to understand the use of medical insurance funds and the patterns of violations, so as to formulate more reasonable medical insurance policies and regulatory measures. However, without effective data storage and analysis methods, the data will be disorganized and difficult to analyze accurately. Based on this, the online supervision system not only synchronously transmits the pharmacy order data to the medical insurance department, but also stores and analyzes the order data, specifically including: classifying and storing the order data according to preset time periods; based on big data analysis technology, statistical analysis of the order data is performed to generate medical insurance fund usage reports and violation analysis reports; and the analysis results are fed back to the medical insurance department to provide data support for medical insurance policy adjustments and regulatory decisions.

[0046] It's worth noting that after order data is synchronously transmitted to the medical insurance department, it's further stored and analyzed. Order data is categorized and stored according to preset time periods to facilitate data management and query. Based on big data analytics technology, statistical analysis of order data is performed to generate reports on medical insurance fund usage and analysis of violations. The analysis results are fed back to the medical insurance department, providing data support for medical insurance policy adjustments and regulatory decisions.

[0047] The technical effects achieved by the above-mentioned embodiments include: Classified storage of order data enables medical insurance departments to quickly and accurately query and retrieve required data, thereby improving data management efficiency. The medical insurance fund usage reports and violation analysis reports generated using big data analysis technology provide comprehensive and in-depth data support for medical insurance departments, enabling them to clearly understand information such as trends in medical insurance fund usage and areas with high incidence of violations. Based on these analysis results, medical insurance departments can scientifically adjust medical insurance policies, optimize regulatory measures, improve the efficiency and security of medical insurance fund use, and achieve scientific and intelligent medical insurance supervision.

[0048] For example, traditional technical solutions have the following technical problems: With the development of Internet medical care, online follow-up prescriptions have gradually become a trend, but the traditional medical insurance supervision system cannot effectively connect with the follow-up prescriptions of Internet medical institutions, resulting in insured people being unable to conveniently obtain medical insurance reimbursement after online follow-up visits. There is also a problem of lack of prescription supervision.

[0049] The online supervision system supports docking with Internet medical institutions that meet the medical insurance management requirements, receives follow-up prescriptions issued by Internet medical institutions, and performs compliance verification on the follow-up prescriptions; when the follow-up prescription passes the verification, a medical insurance order is initiated in the online supervision system based on the follow-up prescription.

[0050] It is worth mentioning that the online supervision system supports connection with internet medical institutions that meet medical insurance management requirements, accepts follow-up prescriptions issued by internet medical institutions, and verifies the compliance of follow-up prescriptions. Once the follow-up prescription passes the verification, a medical insurance order is initiated in the online supervision system based on the prescription, effectively connecting online follow-up prescriptions with medical insurance reimbursement.

[0051] The technical effects achieved by the above embodiments include: enabling integration with internet medical institutions, facilitating online follow-up consultations, prescriptions, and medical insurance reimbursement for insured individuals, improving the convenience and accessibility of medical care, and meeting the public's growing demand for medical services. Compliance verification of follow-up prescriptions ensures the standardization and legality of online prescriptions, effectively preventing the illegal use of medical insurance funds through online prescriptions and ensuring the security of medical insurance funds. At the same time, it promotes the integrated development of internet medical services and medical insurance services, and promotes the innovation and optimization of medical service models.

[0052] The above are merely preferred embodiments of the present invention and do not limit the present invention in any other form. Any technician familiar with the profession may use the technical content disclosed above to change or modify it into an equivalent embodiment with equivalent changes and apply it to other fields. However, any simple modification, equivalent change and modification made to the above embodiment based on the technical essence of the present invention without departing from the content of the technical solution of the present invention shall still fall within the scope of protection of the technical solution of the present invention.

Claims

1. A method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies, characterized by: include: Importing the pharmacy's inventory database into the online supervision system as the pharmacy's commodity basic data in the online supervision system; Pharmacies are restricted to initiating medical insurance orders only through the online supervision system when making sales. The initiation of medical insurance orders through the online supervision system covers all medical insurance reimbursement methods in the daily operation of pharmacies; When a pharmacy places an order through the online supervision system, the online supervision system calls the built-in medical insurance knowledge base and rule base in real time to verify the order, and issues a real-time reminder or intercepts any content that does not comply with the medical insurance fund payment regulations; The online supervision system generates an order information QR code based on the medical insurance order, and the order information QR code is transmitted between related systems. The pharmacy staff completes the price marking, reimbursement and fee information receipt work in sequence based on the order information QR code; The online supervision system synchronously transmits the pharmacy order data to the medical insurance department, realizing the control of the source of billing, the process of billing, the result of charging and the integration of full data.

2. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1 is characterized in that: The method of importing the pharmacy's purchase, sales, and inventory product library into the online supervision system includes: obtaining product information in the pharmacy's purchase, sales, and inventory product library, wherein the product information at least includes product name, specifications, manufacturer, price, and inventory quantity; performing format conversion and standardization processing on the product information so that it complies with the data format requirements of the online supervision system; importing the processed product information into the online supervision system, and establishing a unique correspondence with the actual products of the pharmacy.

3. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1 is characterized in that: The medical insurance order initiation methods of the online supervision system cover all medical insurance reimbursement methods in the daily operation of pharmacies, including: supporting the initiation of medical insurance orders for counter sales, supporting the initiation of medical insurance orders for online drug purchases, and supporting the initiation of medical insurance orders for prescriptions dispensed by designated medical institutions; and each medical insurance order initiation method requires the completion of order information entry, review and submission operations in the online supervision system.

4. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1 is characterized in that: The medical insurance knowledge base includes at least a medical insurance drug catalog, a medical insurance diagnosis and treatment item catalog, and medical insurance service facility standards; the rule base includes at least medical insurance fund payment rules, medical insurance reimbursement ratio rules, and medical insurance drug dosage rules; when the online supervision system calls the medical insurance knowledge base and rule base to perform real-time verification of the orders placed, the verification is performed in sequence according to the preset verification priority order.

5. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 4 is characterized in that: When performing real-time verification on the order placed, the amount payable by the medical insurance fund is calculated based on the following formula: ； in, Indicates the amount that can be paid by the medical insurance fund; Indicates the types and quantities of goods or services in the order; Indicates the order the quantity of the good or service; Indicates the order The unit price of a good or service; Indicates the order The medical insurance reimbursement ratio corresponding to the goods or services, ; Indicates the order The medical insurance payment status mark of the commodity or service When the goods or services meet the medical insurance payment requirements ,otherwise .

6. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 5 is characterized in that: When verification finds that the order contains content that does not comply with the medical insurance fund payment regulations, the violation risk coefficient is calculated based on the following formula: ； in, represents the violation risk coefficient, ; Indicates the types and quantity of goods or services in the order that do not comply with the medical insurance fund payment regulations; Indicates that the order does not comply with the medical insurance fund payment regulations. the quantity of the good or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The unit price of a good or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The medical insurance reimbursement ratio corresponding to the commodity or service; Indicates that the order does not comply with the medical insurance fund payment regulations. The medical insurance payment status mark of the commodity or service When a product or service does not meet the medical insurance payment regulations ; Indicates the types and quantities of goods or services in the order; Indicates the order the quantity of the good or service; Indicates the order The unit price of a good or service; When the preset threshold is exceeded, the online supervision system performs real-time interception.

7. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 6 is characterized in that: When the online supervision system verifies orders in real time, it also evaluates the overall compliance of the orders based on the following formula: ； in, Indicates the overall compliance coefficient of the order, ; Indicates the number of prescription-related verification items involved in the order; Indicates the The weight of each prescription-related verification item, ,and ; Indicates the The compliance status mark of each prescription-related verification item, when the When the relevant verification items of each prescription meet the requirements ,otherwise ; and Respectively represent the compliance weight of medical insurance fund payment and prescription compliance weight, ,and 、 .

8. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1 is characterized in that: The order information QR code includes the order number, pharmacy logo, insured person information, product or service information, and medical insurance fund payment information; the associated systems include the pharmacy cashier system, the medical insurance settlement system, and the medical insurance supervision system; when the order information QR code is transmitted between the associated systems, it is encrypted using an encryption algorithm to ensure data transmission security.

9. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1 is characterized in that: After the online supervision system synchronously transmits the pharmacy order data to the medical insurance department, it also stores and analyzes the order data, specifically including: classifying and storing the order data according to preset time periods; performing statistical analysis on the order data based on big data analysis technology, and generating medical insurance fund usage reports and violation analysis reports; and feeding back the analysis results to the medical insurance department to provide data support for medical insurance policy adjustments and regulatory decisions.

10. The method for online supervision of illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1 is characterized in that: The online supervision system supports docking with Internet medical institutions that meet the medical insurance management requirements, receives follow-up prescriptions issued by Internet medical institutions, and performs compliance verification on the follow-up prescriptions; when the follow-up prescription passes the verification, a medical insurance order is initiated in the online supervision system based on the follow-up prescription.

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