Method and system for graphically setting medical insurance claim payment rule

Abstract

The invention relates to the technical field of medical insurance claim payment, in particular to a method and system for graphically setting a medical insurance claim payment rule, and the method comprises the following steps: 1, building a parameter library: carrying out the classification and arrangement of medical data, medical insurance reimbursement data and underwriting agreement terms according to a commercial medical insurance claim settlement rule, extracting public parameter items, and carrying out the calculation of the parameter library; establishing a parameter library; step 2, compensation rule setting: according to the commercial medical insurance underwriting agreed terms, the compensation rule is set through a graphical interface; and 3, converting the compensation rule into a calculation formula. According to the invention, the medical insurance claim payment rule can be well set.

Description

Technical Field

[0001] The present invention relates to the technical field of medical insurance compensation, and in particular to a method and system for graphically setting medical insurance compensation rules. Background Art

[0002] The traditional commercial insurance claims process is complex and heavily dependent on manual labor, with high claims costs and low efficiency. With the increasing maturity of technologies such as artificial intelligence, OCR technology, natural language processing and deep learning, major commercial insurance companies have launched online claims services, striving to improve users' claims experience through technological capabilities. Summary of the invention

[0003] The present invention provides a method and system for graphically setting medical insurance reimbursement rules, which can better set medical insurance reimbursement rules.

[0004] A method for graphically setting medical insurance reimbursement rules according to the present invention comprises the following steps:

[0005] Step 1: Establish a parameter library: Classify and organize medical data, medical insurance reimbursement data, and underwriting agreement terms according to commercial medical insurance claims rules, extract common parameter items, and establish a parameter library;

[0006] Step 2: Set compensation rules: Set compensation rules through a graphical interface according to the terms of commercial medical insurance underwriting agreement;

[0007] Step 3: Convert the compensation rules into a calculation formula.

[0008] Preferably, in step one, the parameter library includes a medical data parameter library and an insurance agreement data parameter library.

[0009] Preferably, the medical data parameter library includes total costs Y1, costs within the scope of payment by the unified fund Y2, Class B advance out-of-pocket expenses Y3, out-of-pocket expenses exceeding the price limit Y4, out-of-pocket expenses Y5, basic medical insurance payment amount Y6, residents' major disease insurance payment amount Y7, deductible Y8 and hospital grade Y9.

[0010] Preferably, the underwriting agreement data parameter library includes the insured amount C1, the payment ratio C2, the deductible C3, whether social insurance reimbursement C4 and the compensation amount C5.

[0011] Preferably, in step 2, the compensation rules include:

[0012] Claim amount = min ((total cost - Class B advance out-of-pocket expenses - out-of-pocket expenses exceeding the price limit - basic medical insurance payment amount - deductible) * payment ratio, insured amount).

[0013] Preferably, in step 3, the calculation formula includes:

[0014] Claim amount = min((Y1-Y3-Y4-Y6-C3)*C2,C1).

[0015] The present invention provides a system for graphically setting medical insurance compensation rules, which adopts the above-mentioned method for graphically setting medical insurance compensation rules.

[0016] The beneficial effects of the present invention are as follows:

[0017] The present invention allows operators to complete the setting of contract compensation rules by simply dragging and dropping relevant parameters and combining addition, subtraction, multiplication and division operators after carefully reading and fully understanding the key terms of the insurance contract (such as insurance liability, liability exemption, special agreement, etc.). BRIEF DESCRIPTION OF THE DRAWINGS

[0018] Figure 1 The present invention is a flowchart of a method for graphically setting medical insurance reimbursement rules in an embodiment. DETAILED DESCRIPTION

[0019] In order to further understand the content of the present invention, the present invention is described in detail in conjunction with the accompanying drawings and embodiments. It should be understood that the embodiments are only for explaining the present invention and are not intended to limit it.

[0020] Example

[0021] like Figure 1 As shown, this embodiment provides a method for graphically setting medical insurance reimbursement rules, which includes the following steps:

[0022] Step 1: Establish a parameter library: Classify and organize medical data, medical insurance reimbursement data, and underwriting agreement terms according to commercial medical insurance claims rules, extract common parameter items, and establish a parameter library; the parameter library includes a medical data parameter library and an underwriting agreement data parameter library.

[0023] The medical data parameter library includes total costs Y1, costs within the scope of payment from the unified fund Y2, Class B advance out-of-pocket expenses Y3, out-of-pocket expenses exceeding the price limit Y4, out-of-pocket expenses Y5, basic medical insurance payment amount Y6, residents' major disease insurance payment amount Y7, deductible Y8 and hospital grade Y9.

[0024] The underwriting agreement data parameter library includes the insured amount C1, payment ratio C2, deductible C3, whether social insurance reimbursement C4 and compensation amount C5.

[0025] Step 2: Set compensation rules: Set compensation rules through a graphical interface based on the terms of commercial medical insurance underwriting.

[0026] The compensation rules include:

[0027] Claim amount = min ((total cost - Class B advance out-of-pocket expenses - out-of-pocket expenses exceeding the price limit - basic medical insurance payment amount - deductible) * payment ratio, insured amount).

[0028] Step 3: Convert the compensation rules into a calculation formula.

[0029] In step 3, the calculation formula includes:

[0030] Claim amount = min((Y1-Y3-Y4-Y6-C3)*C2,C1).

[0031] This embodiment provides a system for graphically setting medical insurance reimbursement rules, which adopts the above-mentioned method for graphically setting medical insurance reimbursement rules.

[0032] This embodiment allows the operator to complete the setting of contract compensation rules by simply dragging and dropping relevant parameters with addition, subtraction, multiplication and division operators after carefully reading and fully understanding the key terms of the insurance contract (such as insurance liability, liability exemption, special agreements, etc.).

[0033] The present invention and its embodiments are described schematically above, and the description is not restrictive. The drawings show only one embodiment of the present invention, and the actual structure is not limited thereto. Therefore, if a person skilled in the art is inspired by it and designs a structural method and an embodiment similar to the technical solution without creativity without departing from the purpose of the invention, they shall all fall within the protection scope of the present invention.

Claims

1. A method for graphically setting medical insurance compensation rules, characterized by: The following steps are involved: Step 1: Establish a parameter library: Classify and sort medical data, medical insurance reimbursement data, and underwriting agreement terms according to commercial medical insurance claims rules, extract common parameter items, and establish a parameter library; Step 2: Set compensation rules: Set compensation rules through a graphical interface according to the terms of commercial medical insurance underwriting agreement; Step 3: Convert the compensation rules into a calculation formula.

2. A method for graphically setting medical insurance compensation rules according to claim 1, characterized in that: In step one, the parameter library includes a medical data parameter library and an insurance agreement data parameter library.

3. A method for graphically setting medical insurance compensation rules according to claim 2, characterized in that: The medical data parameter library includes total costs Y1, costs within the scope of payment from the unified fund Y2, Class B advance out-of-pocket expenses Y3, out-of-pocket expenses exceeding the price limit Y4, out-of-pocket expenses Y5, basic medical insurance payment amount Y6, residents' major disease insurance payment amount Y7, deductible Y8 and hospital grade Y9.

4. A method for graphically setting medical insurance compensation rules according to claim 3, characterized in that: The underwriting agreement data parameter library includes the insured amount C1, payment ratio C2, deductible C3, whether social insurance reimbursement C4 and compensation amount C5.

5. A method for graphically setting medical insurance compensation rules according to claim 4, characterized in that: In step 2, the compensation rules include: Claim amount = min ((total cost - Class B advance out-of-pocket expenses - out-of-pocket expenses exceeding the price limit - basic medical insurance payment amount - deductible) * payment ratio, insured amount).

6. A method for graphically setting medical insurance compensation rules according to claim 5, characterized in that: In step 3, the calculation formula includes: Claim amount = min((Y1-Y3-Y4-Y6-C3)*C2,C1).

7. A system for graphically setting medical insurance compensation rules, characterized by: It adopts a method for graphically setting medical insurance reimbursement rules as described in any one of claims 1-6.

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