An Internet-based online reservation and insurance claim system and method for special drug insurance

Abstract

The present invention belongs to the field of Internet insurance and claims, and specifically discloses an Internet-based special drug insurance online reservation and insurance and claims system and method, including an underwriting subsystem and a claims subsystem, wherein the underwriting subsystem includes: a user order module, which is used for online users to place orders and purchase and configure rate tables, and the user order module includes a drug, pharmacist, and pharmacy information configuration unit, a rate table configuration unit, and a page configuration unit, wherein the page configuration is used for dynamic configuration of system pages and dynamic configuration of user front-end page display; a risk control verification module, which is used for drug verification of user orders and risk control based on drug rules, and the risk control verification module includes an order verification unit and a cost calculation unit. The present invention strives for preferential drug benefits for users through the model of medical insurance, and the problem of timeliness of medical insurance claims is solved through the advantages of the Internet's fast automatic insurance and automatic claims, and users are unaware of this process.

Description

Technical Field

[0001] The present invention relates to the field of insurance claims settlement on the Internet, and in particular to an online reservation and insurance claims settlement system and method for special drug insurance based on the Internet. Background Art

[0002] With the development of medical technology, there are more and more specialty drugs (drugs with high scientific content and high technical difficulty for special treatment of a certain disease) on the market, such as apatinib mesylate tablets (Eitan) and ruxolitinib tablets (Jekewei); however, the prices of specialty drugs on the market are relatively expensive. In order to reduce the burden on patients, some insurance agencies have proposed to include the medical expenses of specialty drugs in the scope of insurance reimbursement.

[0003] With the development of the Internet, the reservation and insurance of special medicines have been further expanded. The existing reservation and insurance system for special medicines generally generates a group order through the insurance company every day. Every day, the purchase orders generated by users through online reservation purchases are batched into one group order for claims. It has the following problems:

[0004] 1. Drug costs are expensive; 2. Users have fewer options for drug payment methods; 3. Offline claims are all post-insurance, and timeliness cannot be guaranteed. Summary of the invention

[0005] The purpose of the present invention is to provide an Internet-based online reservation and insurance claims system and method for special drug insurance to solve the problems raised in the above-mentioned background technology.

[0006] To achieve the above-mentioned purpose, the present invention provides the following technical solutions: an Internet-based online reservation and insurance claims system and method for special drug insurance, including an underwriting subsystem and a claims settlement subsystem, wherein the underwriting subsystem includes: a user order module, which is used for online users to place orders and configure rate tables, and the user order module includes a drug, pharmacist, and pharmacy information configuration unit, a rate table configuration unit, and a page configuration unit, wherein the page configuration is used for dynamic configuration of system pages and dynamic configuration of user front-end page display; a risk control verification module, which is used for drug verification of user orders and risk control based on drug rules, The risk control verification module includes an order verification unit and a cost calculation unit. The order verification unit is used to verify the total category and maximum number of medicines that can be purchased within the membership period and month purchased by the user; the cost calculation unit is used to push the order payment amount and insurance premium estimate based on the patient's specific symptoms, patient information, patient occupation, pharmacy and medicine; the multi-terminal payment module is used for multi-terminal payment of the system, and multi-terminal payment includes but is not limited to Alipay, WeChat, and UnionPay; the insurance issuance module is used for the insurance issuance of users' orders; the security operation module is used for users' group order discount reduction and cancellation processing.

[0007] Preferably, the claims subsystem includes: a policy association module for associating and managing orders and policies, the policy association module includes: a case management unit for associating orders and policies, pushing premiums, and pushing claims applications; a task scheduling unit for monitoring order review status and order material collection; an incentive rule unit for incentivizing user pharmacists to upload order files, giving users Kangfu Bean discounts and pharmacist points; a material collection module for collecting and centrally managing relevant materials, the material collection module includes a document management unit for centralized management of identity card information, prescriptions, invoices, and claim applications, and storing them on a file server, waiting for premiums to be pushed before making claims applications and reporting; a case review module for reviewing and authority management of cases such as invoices, the case review module includes an authority management unit for authority management of basic reviews by reviewers, and audit log records; an audit log unit for reviewing invoice duplication and invoice verification; a report push module for pushing premiums and claims applications, and then packaging and pushing files to the insurance company for reporting and claims; a case closing batch module for processing online insurance company payment closing information, as well as final status sealing and financial reconciliation of payment information.

[0008] Preferably, the drug, pharmacist, and pharmacy information configuration unit is a configurable platform for users to purchase drugs online, select pharmacies, and pharmacists. The rate table configuration unit is used to configure the currently effective rate table, configure the drugs and discounts in the rate table, that is, when users purchase a membership, they can bind it as a discount voucher when purchasing drugs.

[0009] Preferably, the insurance policy module includes an order management unit and a policy management unit, wherein the order management unit is a drug purchase order information management platform generated by each pharmacy, and the policy management unit can generate an electronic certificate for insurance at the insurance company after the user's order payment is successful.

[0010] The present invention also provides the above-mentioned Internet-based online reservation and insurance claim settlement method for special drug insurance, comprising the following steps:

[0011] S1: A valid rate table is pre-stored in the system, which includes 200 to 300 drugs, SKUs, specifications, manufacturers, and discount amounts;

[0012] S2: The user registers and purchases a membership. The user searches for the current effective rate table and binds the rate table. If the rate table cannot be found, the system prompts the user that there is no effective rate table. The user needs to upload an identity document and conduct an ORC real-name verification. After the verification is passed, the user is granted the right to purchase a membership.

[0013] S3: Calculate the insurance premium based on the drug rate in the rate table. The calculation formula is: insurance premium = total drug amount (claim amount) - discount amount in the rate table;

[0014] S4: The user uploads the accident proof to the system, which includes: invoice, signed claim application form;

[0015] S5: The system verifies invoices, collects prescription user information, and pays the premium to the insurance company after system review and manual basic review;

[0016] S6: User initiates claim online;

[0017] S7: The insurance company returns the claim amount after completing the review.

[0018] Preferably, the system review process in S5 includes checking for invoice duplication and invoice authenticity; identity card information authentication; insurance claim verification, premium, claim amount, and discount.

[0019] Preferably, the S7 China Insurance Company's audit strategy is to verify whether the ID card information is the patient's and is valid, whether the purchased medicines and prescription invoices are consistent, the invoice amount and the claim amount are consistent, the applicant information on the claim application form is consistent with the patient information, the accident location is the pharmacy, the claim amount is the total amount of the medicines, i.e. the invoice amount, and whether there is the patient's CA signature.

[0020] Compared with the prior art, the present invention has the following beneficial effects:

[0021] The present invention obtains preferential medication benefits for users through the medical insurance model. The problem of time limit for medical insurance claims is solved through automatic insurance and automatic claims settlement via the Internet, and the preferential benefits of patients are subsidized by the insurance company in the form of insurance claims, which alleviates the problem of difficulty and high cost of drug purchase for users. At the same time, the user's insurance claims process is efficiently solved without the user feeling anything. BRIEF DESCRIPTION OF THE DRAWINGS

[0022] Figure 1 is a flow chart of the system method of the present invention;

[0023] Figure 2 It is a module block diagram of the underwriting subsystem of the present invention;

[0024] Figure 3 This is a module block diagram of the claims settlement subsystem of the present invention. DETAILED DESCRIPTION

[0025] The following will be combined with the drawings in the embodiments of the present invention to clearly and completely describe the technical solutions in the embodiments of the present invention. Obviously, the described embodiments are only part of the embodiments of the present invention, not all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by ordinary technicians in this field without creative work are within the scope of protection of the present invention.

[0026] See also Figure 1-3The present invention provides a technical solution: an online reservation and insurance claim settlement system and method for special drug insurance based on the Internet, including an underwriting subsystem and a claim settlement subsystem, wherein the underwriting subsystem includes:

[0027] User order module, used for online user ordering and rate table configuration. The user order module includes drug, pharmacist, pharmacy information configuration unit, rate table configuration unit and page configuration unit. The page configuration is used for dynamic configuration of system pages and dynamic configuration of user front-end page display;

[0028] The risk control verification module is used for drug verification of user orders and risk control based on drug rules. The risk control verification module includes an order verification unit and a cost calculation unit. The order verification unit is used to verify the total category and maximum number of drugs that can be purchased by the user during the membership period and month.

[0029] Cost calculation unit, used to push the order payment amount and insurance premium estimate based on the patient's specific symptoms, patient information, patient occupation, drug purchase pharmacy and drugs;

[0030] The multi-terminal payment module is used for multi-terminal payment of the system, including but not limited to Alipay, WeChat, and UnionPay; the insurance and billing module is used for the insurance and billing of the user's order;

[0031] The security operation module is used for group discount reduction and insurance cancellation processing for users.

[0032] In this embodiment, the claims settlement subsystem includes:

[0033] The policy association module is used for order and policy association and management. The policy association module includes: case management unit, which is used for order and policy association, premium push, and claim application push; task scheduling unit, which is used to monitor order review status and order material collection; incentive rule unit, which is used to encourage user pharmacists to upload order files and give users Kangfudou discounts and pharmacist points;

[0034] The material collection module is used for the collection and centralized management of relevant materials. The material collection module includes a document management unit, which is used for the centralized management of ID card information, prescriptions, invoices, and claim application forms and their storage in the file server, waiting for the premium to be pushed before applying for claims and reporting the case;

[0035] The case review module is used for reviewing and managing the rights of invoices and other cases. The case review module includes a rights management unit for the rights management of basic reviews by reviewers and audit log records; an audit log unit for reviewing invoice duplication and invoice verification;

[0036] The report push module is used to push the premium and claim application, and then package the files and push them to the insurance company for reporting and claim settlement;

[0037] The case closing batch module is used for online insurance company payment closing information processing, as well as final status sealing and financial reconciliation of payment information.

[0038] In this embodiment, the drug, pharmacist, and pharmacy information configuration unit is a configurable platform for users to purchase drugs online, select pharmacies, drugs, and pharmacists. The rate table configuration unit is used to configure the currently effective rate table, configure the drugs and discounts in the rate table, that is, when users purchase a membership, they can bind it as a discount voucher when purchasing drugs.

[0039] In this embodiment, the insurance policy module includes an order management unit and a policy management unit, wherein the order management unit is a drug purchase order information management platform generated by each pharmacy, and the policy management unit can generate an electronic certificate for insurance at the insurance company after the user's order payment is successful.

[0040] The present invention also provides the above-mentioned Internet-based online reservation and insurance claim settlement method for special drug insurance, comprising the following steps:

[0041] S1: A valid rate table is pre-stored in the system, which includes 200 to 300 drugs, SKUs, specifications, manufacturers, and discount amounts;

[0042] S2: The user registers and purchases a membership. The user searches for the current effective rate table and binds the rate table. If the rate table cannot be found, the system prompts the user that there is no effective rate table. The user needs to upload an identity document and conduct an ORC real-name verification. After the verification is passed, the user is granted the right to purchase a membership.

[0043] S3: Calculate the insurance premium based on the drug rate in the rate table. The calculation formula is: insurance premium = total drug amount (claim amount) - discount amount in the rate table;

[0044] S4: The user uploads the accident proof to the system, which includes: invoice, signed claim application form;

[0045] S5: The system verifies invoices, collects prescription user information, and pays the premium to the insurance company after system review and manual basic review;

[0046] S6: User initiates claim online;

[0047] S7: The insurance company returns the claim amount after completing the review.

[0048] In this embodiment, the system audit process in S5 includes checking for invoice duplication and invoice authenticity; identity card information authentication; insurance claim verification, premium, claim amount, and discount.

[0049] In this embodiment, the S7 insurance company's audit strategy is: verify whether the ID card information is the patient's and is valid, whether the purchased medicine and prescription invoices are consistent, the invoice amount and the claim amount are consistent, the applicant information of the claim application form and the patient information are consistent, the accident location is the pharmacy, the claim amount is the total amount of the medicine, that is, the invoice amount, and whether there is the patient's CA signature.

[0050] Working Principle:.

[0051] It is worth noting that the entire device is controlled by a main control button. Since the device matched with the control button is a common device and belongs to the existing mature technology, its electrical connection relationship and specific circuit structure will not be described in detail here.

[0052] Although embodiments of the present invention have been shown and described, it will be appreciated by those skilled in the art that various changes, modifications, substitutions and variations may be made to the embodiments without departing from the principles and spirit of the present invention, and that the scope of the present invention is defined by the appended claims and their equivalents.

Claims

1. An Internet-based online reservation and insurance claim system for special drug insurance, characterized in that: It includes underwriting subsystem and claims settlement subsystem, where the underwriting subsystem includes: User order module, used for online user ordering and rate table configuration. The user order module includes drug, pharmacist, pharmacy information configuration unit, rate table configuration unit and page configuration unit. The page configuration is used for dynamic configuration of system pages and dynamic configuration of user front-end page display; The risk control verification module is used for drug verification of user orders and risk control based on drug rules. The risk control verification module includes an order verification unit and a cost calculation unit. The order verification unit is used to verify the total category and maximum number of drugs that can be purchased by the user during the membership period and month. Cost calculation unit, used to estimate the payment amount and insurance premium according to the patient's specific symptoms, patient information, patient occupation, drug purchase pharmacy, and drug push order; The multi-terminal payment module is used for multi-terminal payment of the system, including but not limited to Alipay, WeChat, and UnionPay; the insurance and billing module is used for the insurance and billing of the user's order; The security operation module is used for group discount reduction and insurance cancellation processing for users; The claims settlement subsystem includes: The policy association module is used for order and policy association and management. The policy association module includes: case management unit, which is used for order and policy association, premium push, and claim application push; task scheduling unit, which is used to monitor order review status and order material collection; incentive rule unit, which is used to encourage user pharmacists to upload order files and give users Kangfudou discounts and pharmacist points; The material collection module is used for the collection and centralized management of relevant materials. The material collection module includes a document management unit, which is used for the centralized management of ID card information, prescriptions, invoices, and claim application forms and their storage in the file server, waiting for the premium to be pushed before applying for claims and reporting the case; The case review module is used for invoice review and authority management. The case review module includes the authority management unit, which is used for authority management of basic review by reviewers and audit log records; the audit log unit is used to review invoice duplication and invoice verification; The report push module is used to push the premium and claim application, and then package the files and push them to the insurance company for reporting and claim settlement; The case closing batch module is used for online insurance company payment closing information processing, as well as final status sealing and financial reconciliation of payment information.

2. According to claim 1, an Internet-based online reservation and insurance claim system for special drug insurance is characterized by: The drug, pharmacist, and drugstore information configuration unit is a configurable platform for users to purchase drugs online, select pharmacies, and pharmacists. The rate table configuration unit is used to configure the currently effective rate table, and configure the drugs and discounts in the rate table, that is, when users purchase a membership, they can bind it as a discount voucher when purchasing drugs.

3. The Internet-based online reservation and insurance claim system for special drug insurance according to claim 1 is characterized by: The insurance policy module includes an order management unit and a policy management unit, wherein the order management unit is a drug purchase order information management platform generated by each pharmacy, and the policy management unit can generate an electronic certificate for insurance at the insurance company after the user's order payment is successful.

4. An online reservation and insurance claim settlement method for special drug insurance based on the Internet, based on the implementation of an online reservation and insurance claim settlement system for special drug insurance based on the Internet as described in any one of claims 1 to 3, characterized in that: The steps include: S1: Pre-store an effective rate table in the system, which includes drugs, sku, specifications, manufacturers, and discount amounts; S2: The user registers and purchases a membership. The user searches for the current effective rate table and binds the rate table. If the rate table cannot be found, the system prompts the user that there is no effective rate table. The user needs to upload an identity document and conduct an ORC real-name verification. After the verification is passed, the user is granted the right to purchase a membership. S3: Calculate the insurance premium based on the drug rate in the rate table. The formula is: insurance premium = total drug amount - discount amount in the rate table. The total drug amount is the claim amount. S4: The user uploads the accident proof to the system, which includes: invoice, signed claim application form; S5: The system verifies invoices, collects prescription user information, and pays the premium to the insurance company after system review and manual basic review; S6: User initiates claim online; S7: The insurance company returns the claim amount after completing the review.

5. According to claim 4, the method for online reservation and insurance claim settlement of special drug insurance based on the Internet is characterized in that: The system audit process in S5 includes checking for invoice duplication and invoice verification; identity card information authentication; insurance claim verification, premium, claim amount, and discount.

6. The method for online reservation and insurance claim settlement of special drug insurance based on the Internet according to claim 4, characterized in that: The S7 China Insurance Company's audit strategy is to verify whether the ID card information is the patient's and is valid, whether the purchased medicines and prescription invoices are consistent, the invoice amount and the claim amount are consistent, the applicant information on the claim application is consistent with the patient information, the accident location is the pharmacy, the claim amount is the total amount of the medicines, i.e. the invoice amount, and whether there is the patient's CA signature.

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