Medical insurance outpatient service payment management system and method

Abstract

The invention relates to the field of medical insurance management, and discloses a medical insurance outpatient service payment management system and method, and the system comprises a doctor seeing information module, a medical insurance information module, a classification module, and an analysis module. Firstly, a doctor-seeing information module obtains doctor-seeing information data; acquiring medical insurance information data through a medical insurance information module; then, the doctor seeing persons are divided into effective medical insurance doctor seeing persons and invalid medical insurance doctor seeing persons through a classification module; and finally, analyzing the doctor-seeing information data of the effective medical insurance doctor, the medical insurance information data and the doctor-seeing information data of the invalid medical insurance doctor through an analysis module, judging whether the medical insurance payment of the hospital is abnormal or not, if so, performing early warning, and performing early warning on the condition that the medical insurance payment is abnormal in the medical insurance of the hospital. And non-compliance behaviors such as frequent medical treatment seeing, improper banking and medical treatment seeing and improper head pulling in the hospital are avoided.

Description

Technical Field

[0001] The present invention relates to the field of medical insurance management, and in particular to a medical insurance outpatient payment management system and method. Background Art

[0002] Medical insurance is an insurance system established to compensate workers for economic losses caused by disease risks. Medical insurance has different policies for outpatient and inpatient care, and the reimbursement ratio and limit for outpatient care are usually lower.

[0003] As the outpatient medical insurance fund expenditure increases year by year, outpatient payment has also attracted more attention. The current outpatient payment is mainly based on item payment, which lacks sufficient advantages in medical insurance cost control; therefore, the outpatient payment method has been changed to an outpatient payment method based on the effective per capita point method under the regional total budget. That is, under the condition of determining the total budget of the medical insurance outpatient department in the coordinated area, the effective per capita payment is converted into a certain point as a payment unit, and payment is made according to the total point number of outpatient services of each medical institution.

[0004] However, in actual operations, abnormal and irregular behaviors such as frequent medical treatment, improper group medical treatment, and improper medical treatment may occur in medical practices, resulting in a large amount of waste of medical insurance funds. Summary of the invention

[0005] The purpose of the present invention is to provide a medical insurance outpatient payment management system and method to solve the following technical problems: How to promptly detect abnormal and irregular behaviors in hospital medical insurance payments.

[0006] The purpose of the present invention can be achieved through the following technical solutions: A medical insurance outpatient payment management system, the payment management system comprising: The medical consultation information module is used to obtain the medical consultation information data of each hospital outpatient department during the settlement period; the medical consultation information data includes the patient; The medical insurance information module is used to obtain the medical insurance information data of each patient; A classification module is used to classify patients with valid medical insurance and patients with invalid medical insurance according to medical insurance information data; The analysis module is used to analyze the medical information data of valid medical insurance patients, medical insurance information data and medical information data of invalid medical insurance patients, to determine whether there are any abnormalities in the hospital's medical insurance payment. If there are any abnormalities, an early warning will be issued and the medical insurance payment supervision department will conduct an examination. If there are no abnormalities, the medical insurance payment supervision department will pay the hospital's outpatient services according to the valid medical insurance patient capitation method.

[0007] As a further solution of the present invention: the analysis process of the analysis module includes: S10: Obtain the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits of each department through medical information data and medical insurance information data; S20: Obtain the first judgment index of each department of the hospital by analyzing the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits in each department; S30: Obtaining the comprehensive judgment index of the hospital by analyzing the first judgment index of each department; S40: Assess the abnormal risk of the hospital's medical insurance payment based on the hospital's comprehensive judgment index, and issue corresponding warnings to the medical insurance payment supervision department.

[0008] As a further solution of the present invention: by formula:

[0009] Calculate the hospital's first The first judgment index of each department ; in, is the judgment function, when hour, ;when hour, ; This is the first Number of patients with valid medical insurance in each department; This is the first time that the hospital The number of patients with valid medical insurance in each department; This is the first Number of invalid medical insurance visits in each department; This is the first The number of patients with invalid medical insurance in each department; This is the hospital's first The first comparison ratio of each department; This is the first The error adjustment factor for each department; The preset allowable error value.

[0010] As a further solution of the present invention: by formula:

[0011] Calculate the hospital's first The first comparison ratio of each department ; in, is the number of historical settlement periods within the past preset time period, ; The number of During the historical settlement period, the hospital Number of patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital The number of patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital Number of invalid medical insurance visits in each department; The number of During the historical settlement period, the hospital The number of patients with invalid medical insurance in each department; The number of The weight coefficient of the historical settlement period.

[0012] As a further solution of the present invention: by formula:

[0013] Calculate the hospital's first Error adjustment factor for each department ; in, is the first preset constant; is the first preset comparison value.

[0014] As a further solution of the present invention: by formula:

[0015] Calculate the comprehensive judgment index of the hospital during this settlement period ; in, is the number of departments in the hospital, .

[0016] As a further solution of the present invention: the process of abnormal risk rating of hospital medical insurance payment is: The comprehensive judgment index With the first preset threshold Make a comparison; when When the hospital's medical insurance abnormal risk level is no risk, no warning is required; when When the hospital's medical insurance abnormality risk level is low, a level 1 warning is issued; when When the hospital's medical insurance abnormality risk level is medium risk, a level 2 warning is issued; when At that time, the hospital's medical insurance abnormality risk level was high risk, and a third-level warning was issued.

[0017] A medical insurance outpatient payment management method, the payment management method comprising the following steps: S1: Obtain the outpatient medical information data of each hospital during the settlement period through the medical information module; S2: Obtain the medical insurance information data of each patient through the medical insurance information module; S3: Classify patients into valid medical insurance patients and invalid medical insurance patients according to medical insurance information data through a classification module; S4: The analysis module is used to analyze the medical information data of valid medical insurance patients, medical insurance information data and medical information data of invalid medical insurance patients to determine whether there are any abnormalities in the hospital's medical insurance payment. If there are any abnormalities, an early warning will be issued and the medical insurance payment supervision department will conduct an examination. If there are no abnormalities, the medical insurance payment supervision department will pay the hospital's outpatient services according to the valid medical insurance patient capitation method.

[0018] Beneficial effects of the present invention: (1) The present invention first obtains the medical information data of each hospital outpatient clinic during the settlement period through the medical information module; then obtains the medical insurance information data of each patient through the medical insurance information module; then divides the patients into valid medical insurance patients and invalid medical insurance patients according to the medical insurance information data through the classification module; finally, the medical information data of the valid medical insurance patients, the medical insurance information data and the medical information data of the invalid medical insurance patients are analyzed through the analysis module to determine whether there is any abnormality in the hospital's medical insurance payment. If there is any abnormality, an early warning is issued and the medical insurance payment supervision department conducts an examination. If there is no abnormality, the medical insurance payment supervision department pays the hospital outpatient service according to the valid medical insurance patient head point method; an early warning is issued for the presence of abnormal medical insurance payment in the hospital medical insurance to avoid non-compliant behaviors such as frequent medical treatment, improper group medical treatment, and improper head medical treatment in the hospital; (2) The present invention first obtains the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits and the number of invalid medical insurance visits of each department through medical information data and medical insurance information data; then, by analyzing the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits and the number of invalid medical insurance visits of each department, a first judgment index of each department of the hospital is obtained; then, by analyzing the first judgment index of each department, a comprehensive judgment index of the hospital is obtained; finally, according to the comprehensive judgment index of the hospital, an abnormal risk rating of the hospital's medical insurance payment is performed, and a corresponding warning is issued to the medical insurance payment supervision department; so that the medical insurance payment supervision department can conduct a corresponding level of review according to different warning levels, thereby avoiding the occurrence of non-compliant behaviors such as frequent medical treatment, improper group medical treatment, improper medical treatment by pulling people to see a doctor, and avoiding a large amount of manpower, material resources and time wasted in the review process. BRIEF DESCRIPTION OF THE DRAWINGS

[0019] The present invention will be further described below in conjunction with the accompanying drawings.

[0020] Figure 1 A system module framework diagram of an embodiment of the present invention; Figure 2 The present invention is a method flow chart of an embodiment of the present invention. DETAILED DESCRIPTION

[0021] 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.

[0022] See also Figure 1 As shown, in one embodiment, a medical insurance outpatient payment management system is provided, including: The medical consultation information module is used to obtain the medical consultation information data of each hospital outpatient department during the settlement period; the medical consultation information data includes the patient; The medical insurance information module is used to obtain the medical insurance information data of each patient; A classification module is used to classify patients with valid medical insurance and patients with invalid medical insurance according to medical insurance information data; The analysis module is used to analyze the medical information data of valid medical insurance patients, medical insurance information data and medical information data of invalid medical insurance patients to determine whether there are any abnormalities in the hospital's medical insurance payment. If there are any abnormalities, an early warning will be issued and the medical insurance payment supervision department will conduct an examination. If there are no abnormalities, the medical insurance payment supervision department will pay the hospital's outpatient services according to the valid medical insurance patient capitation method.

[0023] Through the above technical scheme, in this embodiment, the medical information module first obtains the medical information data of each hospital outpatient department during the settlement period; then obtains the medical insurance information data of each patient through the medical insurance information module; then the classification module divides the patients into valid medical insurance patients and invalid medical insurance patients according to the medical insurance information data; finally, the analysis module analyzes the medical information data of the valid medical insurance patients, the medical insurance information data and the medical information data of the invalid medical insurance patients to determine whether there is any abnormality in the hospital's medical insurance payment. If there is any abnormality, an early warning is issued and the medical insurance payment supervision department conducts an examination. If there is no abnormality, the medical insurance payment supervision department pays the hospital outpatient service according to the valid medical insurance patient head point method; an early warning is issued for the presence of abnormal medical insurance payment in the hospital medical insurance to avoid non-compliant behaviors such as frequent medical treatment, improper group medical treatment, and improper head medical treatment in the hospital.

[0024] As an implementation manner of the present invention, the analysis process of the analysis module includes: S10: Obtain the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits of each department through medical information data and medical insurance information data; S20: Obtain the first judgment index of each department of the hospital by analyzing the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits in each department; S30: Obtaining the comprehensive judgment index of the hospital by analyzing the first judgment index of each department; S40: Rating the abnormal risk of hospital medical insurance payment based on the hospital's comprehensive judgment index, and issuing corresponding warnings to the medical insurance payment supervision department; Through the above technical scheme, this embodiment first obtains the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits of each department through medical information data and medical insurance information data; then, the first judgment index of each department of the hospital is obtained by analyzing the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits of each department; then, the comprehensive judgment index of the hospital is obtained by analyzing the first judgment index of each department; finally, according to the comprehensive judgment index of the hospital, the abnormal risk rating of the hospital's medical insurance payment is performed, and a corresponding warning is issued to the medical insurance payment supervision department; the medical insurance payment supervision department can conduct a corresponding level of review according to different warning levels, so as to avoid the occurrence of non-compliant behaviors such as frequent medical treatment, improper team medical treatment, improper medical treatment, etc. in the hospital, while avoiding a lot of manpower, material resources and time wasted in the review process.

[0025] As an implementation mode of the present invention, by formula:

[0026] Calculate the hospital's first The first judgment index of each department ; in, is the judgment function, when hour, ;when hour, ; This is the first Number of patients with valid medical insurance in each department; This is the first The number of patients with valid medical insurance in each department; This is the first Number of invalid medical insurance visits in each department; This is the first The number of patients with invalid medical insurance in each department; This is the hospital's first The first comparison ratio of each department; This is the first The error adjustment factor for each department; is the preset allowable error value; Through the above technical solution, this embodiment This is the first The average number of visits by patients with valid medical insurance in each department; This is the first The average number of visits by patients with invalid medical insurance in each department; This is the first The average number of visits by patients with valid medical insurance in each department is the same as the average number of visits by the hospital’s first The difference in the average number of visits of invalid medical insurance patients in each department; This is the first The average number of visits by patients with valid medical insurance in each department is the same as the average number of visits by the hospital’s first The difference between the average number of visits of invalid medical insurance patients in each department and the average number of visits of the hospital’s first department in the current settlement period. The ratio of the average number of visits of invalid medical insurance patients to the average number of visits of each department; This is the first The average number of visits by patients with valid medical insurance in each department is the same as the average number of visits by the hospital’s first The difference between the average number of visits of invalid medical insurance patients in each department and the average number of visits of the hospital’s first department in the current settlement period. The ratio of the average number of invalid medical insurance visits in each department to the number of invalid medical insurance visits in the hospital during the historical settlement period. The difference of the first comparison ratio of each department; This is the first The preset allowable error value of each department; in the formula , judgment function In Refers to ;when When the hospital The average number of visits by patients with valid medical insurance in each department is the same as the average number of visits by the hospital’s first The difference between the average number of visits of invalid medical insurance patients in each department and the average number of visits of the hospital’s first department in the current settlement period. The ratio of the average number of invalid medical insurance visits in each department to the number of invalid medical insurance visits in the hospital during the historical settlement period. The difference between the first comparison ratios of the departments is the first The preset allowable error value of each department is within the range, so there is no abnormality. ;when When the hospital The average number of visits by patients with valid medical insurance in each department is the same as the average number of visits by the hospital’s first The difference between the average number of visits of invalid medical insurance patients in each department and the average number of visits of the hospital’s first department in the current settlement period. The ratio of the average number of invalid medical insurance visits in each department to the number of invalid medical insurance visits in the hospital during the historical settlement period. The difference in the first comparison ratio of each department exceeds the first comparison ratio of the hospital during the settlement period. The preset allowable error value range of each department, so there is an abnormality, ; It should be noted that the preset allowable error value It is a preset value obtained based on experience and will not be described in detail here.

[0027] As an implementation mode of the present invention, by formula:

[0028] Calculate the hospital's first The first comparison ratio of each department ; in, is the number of historical settlement periods within the past preset time period, ; The number of During the historical settlement period, the hospital Number of patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital The number of patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital Number of invalid medical insurance visits in each department; The number of During the historical settlement period, the hospital The number of patients with invalid medical insurance in each department; The number of The weight coefficient of each historical settlement period; Through the above technical solution, this embodiment The number of During the historical settlement period, the hospital The average number of visits by patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital The average number of visits by patients with invalid medical insurance in each department; The number of During the historical settlement period, the hospital The average number of visits of patients with valid medical insurance in each department and the number of visits in the past preset time period During the historical settlement period, the hospital The difference in the average number of visits of invalid medical insurance patients in each department; The number of During the historical settlement period, the hospital The average number of visits of patients with valid medical insurance in each department and the number of visits in the past preset time period During the historical settlement period, the hospital The difference between the average number of visits of invalid medical insurance patients in each department and the number of visits in the past preset time period During the historical settlement period, the hospital The ratio of the average number of invalid medical insurance visits to the number of invalid medical insurance visits in each department; the historical settlement periods are numbered in chronological order; the historical settlement period closest to the current settlement period is the first Historical settlement period, the first settlement period in the past preset time period Weight coefficient for each settlement period is the default value, ;No. The weight coefficient of the historical settlement period is the largest; The weight coefficient of the historical settlement option is the largest; It should be noted that the number of historical settlement periods within the past preset time period , No. Weight coefficient for each settlement period It is a preset value obtained based on experience and will not be described in detail here.

[0029] As an implementation mode of the present invention, by formula:

[0030] Calculate the hospital's first Error adjustment factor for each department ; in, is the first preset constant; is a first preset comparison value; Through the above technical solution, this embodiment For the preset time period in the past During the historical settlement period, the hospital The average number of visits of patients with valid medical insurance in each department and the number of visits in the past preset time period During the historical settlement period, the hospital The difference between the average number of visits of invalid medical insurance patients in each department and the number of visits in the past preset time period During the historical settlement period, the hospital The standard deviation of the ratio of the average number of visits of invalid medical insurance patients in each department; is the difference between the standard deviation and the first preset comparison value; when hour, ; The difference between the standard deviation and the first preset comparison value The larger the hospital is during this settlement period. Error adjustment factor for each department The bigger; when hour, ; The difference between the standard deviation and the first preset comparison value The larger the absolute value is; the greater the hospital's Error adjustment factor for each department The smaller; It should be noted that the first preset constant Compare with the first preset value It is a preset value obtained based on experience and will not be described in detail here.

[0031] As an implementation mode of the present invention, by formula:

[0032] Calculate the comprehensive judgment index of the hospital during this settlement period ; in, is the number of departments in the hospital, ; The process of abnormal risk rating for hospital medical insurance payments is as follows: The comprehensive judgment index With the first preset threshold Make a comparison; when When the hospital's medical insurance abnormal risk level is no risk, no warning is required; when When the hospital's medical insurance abnormality risk level is low, a level 1 warning is issued; when When the hospital's medical insurance abnormality risk level is medium risk, a level 2 warning is issued; when When the hospital's medical insurance abnormal risk level is high, a level 3 warning is issued; Through the above technical solution, this embodiment The first judgment index of all departments of the hospital during this settlement period The cumulative value of When the first judgment index of all departments is All are 0; there are no abnormalities, so the hospital's medical insurance abnormality risk level is no risk, no warning is required; when When , it means that only a few departments of the hospital have abnormalities and the abnormal risk is low, so a first-level warning is sent, and medical insurance payment can be made first. Then the medical insurance payment supervision department randomly selects a small amount of medical information from the departments with abnormalities for review; when When the number of abnormal departments in the hospital is small, the risk of abnormality is medium. The medical insurance payment supervision department randomly selects a large amount of medical information from the abnormal departments for review. After the review is clear, medical insurance payment will be made. When the number of abnormalities is high, it means that a large number of departments in the hospital have abnormalities and the abnormality risk is high; the medical insurance payment supervision department randomly selects a large amount of medical information from all departments for review; medical insurance payment is made only after no problems are found in the review; It should be noted that the first preset threshold It is a preset value obtained based on experience and will not be described in detail here.

[0033] See also Figure 2 As shown, a medical insurance outpatient payment management method, the payment management method comprises the following steps: S1: Obtain the outpatient medical information data of each hospital during the settlement period through the medical information module; S2: Obtain the medical insurance information data of each patient through the medical insurance information module; S3: Classify patients into valid medical insurance patients and invalid medical insurance patients according to medical insurance information data through a classification module; S4: The analysis module is used to analyze the medical information data of valid medical insurance patients, medical insurance information data and medical information data of invalid medical insurance patients to determine whether there are any abnormalities in the hospital's medical insurance payment. If there are any abnormalities, an early warning will be issued and the medical insurance payment supervision department will conduct an examination. If there are no abnormalities, the medical insurance payment supervision department will pay the hospital's outpatient services according to the valid medical insurance patient capitation method.

[0034] The above is a detailed description of an embodiment of the present invention, but the content is only a preferred embodiment of the present invention and cannot be considered to limit the scope of implementation of the present invention. All equivalent changes and improvements made within the scope of the present invention should still fall within the scope of the patent coverage of the present invention.

Claims

1. A medical insurance outpatient payment management system, characterized in that: The payment management system comprises: The medical consultation information module is used to obtain the medical consultation information data of each hospital outpatient department during the settlement period; the medical consultation information data includes the patient; The medical insurance information module is used to obtain the medical insurance information data of each patient; A classification module is used to classify patients with valid medical insurance and patients with invalid medical insurance according to medical insurance information data; The analysis module is used to analyze the medical information data of valid medical insurance patients, medical insurance information data and medical information data of invalid medical insurance patients, to determine whether there are any abnormalities in the hospital's medical insurance payment. If there are any abnormalities, an early warning will be issued and the medical insurance payment supervision department will conduct an examination. If there are no abnormalities, the medical insurance payment supervision department will pay the hospital's outpatient services according to the valid medical insurance patient capitation method.

2. A medical insurance outpatient payment management system according to claim 1, characterized in that: The analysis process of the analysis module includes: S10: Obtain the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits of each department through medical information data and medical insurance information data; S20: Obtain the first judgment index of each department of the hospital by analyzing the number of valid medical insurance visits, the number of valid medical insurance visits, the number of invalid medical insurance visits, and the number of invalid medical insurance visits in each department; S30: Obtaining the comprehensive judgment index of the hospital by analyzing the first judgment index of each department; S40: Assess the abnormal risk of the hospital's medical insurance payment based on the hospital's comprehensive judgment index, and issue corresponding warnings to the medical insurance payment supervision department.

3. A medical insurance outpatient payment management system according to claim 2, characterized in that: By formula: ； Calculate the hospital's first The first judgment index of each department ; in, is the judgment function, when hour, ;when hour, ; This is the first Number of patients with valid medical insurance in each department; This is the first The number of patients with valid medical insurance in each department; This is the first Number of invalid medical insurance visits in each department; This is the first The number of patients with invalid medical insurance in each department; This is the hospital's first The first comparison ratio of each department; This is the first time that the hospital The error adjustment factor for each department; The preset allowable error value.

4. A medical insurance outpatient payment management system according to claim 3, characterized in that: By formula: ； Calculate the hospital's first The first comparison ratio of each department ; in, is the number of historical settlement periods within the past preset time period, ; The number of During the historical settlement period, the hospital Number of patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital The number of patients with valid medical insurance in each department; The number of During the historical settlement period, the hospital Number of invalid medical insurance visits in each department; The number of During the historical settlement period, the hospital The number of patients with invalid medical insurance in each department; The number of The weight coefficient of the historical settlement period.

5. A medical insurance outpatient payment management system according to claim 4, characterized in that: By formula: ； Calculate the hospital's first Error adjustment factor for each department ; in, is the first preset constant; is the first preset comparison value.

6. A medical insurance outpatient payment management system according to claim 5, characterized in that: By formula: ； Calculate the comprehensive judgment index of the hospital during this settlement period ; in, is the number of departments in the hospital, .

7. A medical insurance outpatient payment management system according to claim 6, characterized in that: The process of abnormal risk rating for hospital medical insurance payments is as follows: The comprehensive judgment index With the first preset threshold Make a comparison; when When the hospital's medical insurance abnormal risk level is no risk, no warning is required; when When the hospital's medical insurance abnormality risk level is low, a level 1 warning is issued; when When the hospital's medical insurance abnormality risk level is medium risk, a level 2 warning is issued; when At that time, the hospital's medical insurance abnormality risk level was high risk, and a third-level warning was issued.

8. A medical insurance outpatient payment management method, applicable to a medical insurance outpatient payment management system according to any one of claims 1 to 7, characterized in that: The payment management method comprises the following steps: S1: Obtain the outpatient medical information data of each hospital during the settlement period through the medical information module; S2: Obtain the medical insurance information data of each patient through the medical insurance information module; S3: Classify patients into valid medical insurance patients and invalid medical insurance patients according to medical insurance information data through a classification module; S4: The analysis module is used to analyze the medical information data of valid medical insurance patients, medical insurance information data and medical insurance information data of invalid medical insurance patients to determine whether there are any abnormalities in the hospital's medical insurance payment. If there are any abnormalities, an early warning will be issued and the medical insurance payment supervision department will conduct an examination. If there are no abnormalities, the medical insurance payment supervision department will pay for the outpatient services of each hospital according to the valid medical insurance patient capitation method.

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