Method for online supervision of medical insurance fund abuse by medical insurance designated retail pharmacies

Abstract

The present application relates to the technical field of medical insurance supervision, and particularly relates to a method for online supervision of irregular use of medical insurance fund by medical insurance designated retail pharmacies. The method comprises the following steps: importing a medicine store commodity warehouse into an online supervision system as commodity basic data of the medicine store in the online supervision system; limiting the medicine store to only initiate a medical insurance order through the online supervision system when performing a sales behavior, and the medical insurance order initiation mode of the online supervision system covers all medical insurance reimbursement modes in the daily operation process of the medicine store; in the process of initiating an order by the medicine store 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 perform real-time verification on the initiated order, and performs real-time reminding or interception on the content that does not conform to the medical insurance fund payment provisions. The present application can prevent irregular behaviors from the source and guarantee the reasonable and safe use of medical insurance fund.

Description

Technical Field

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

[0002] In the supervision of designated medical insurance retail pharmacies, ensuring the safe use of medical insurance funds is crucial. Currently, the centralized cloud MIS system solution is widely used in the traditional supervision model for designated medical insurance retail pharmacies. However, this solution has significant drawbacks, the most prominent being its inability to effectively monitor the use of medical insurance funds before and during the process. The existing solution can only extract inventory data after medical insurance reimbursement is completed, as an aid to on-site inspections to identify violations. It is difficult to intercept or alert to violations online during the reimbursement process at designated retail pharmacies. This results in many violations of medical insurance fund usage being discovered only after they occur, posing a significant risk of loss to the medical insurance fund, and incurring high costs for subsequent tracing and processing. As the scale of medical insurance fund usage continues to expand and the usage scenarios become increasingly complex...

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

[0004] The purpose of this invention is to address the shortcomings of existing technologies by proposing an online monitoring method for the illegal use of medical insurance funds by designated medical insurance retail pharmacies, comprising:

[0005] Import the pharmacy's inventory of goods into the online monitoring system, which will serve as the basic data for the pharmacy's goods in the online monitoring system.

[0006] When conducting sales, pharmacies are restricted to initiating medical insurance orders only through the online monitoring system. The online monitoring system covers all medical insurance reimbursement methods used by pharmacies in their daily operations.

[0007] During the process of a pharmacy initiating an order through the online monitoring system, the online monitoring system calls the built-in medical insurance knowledge base and rule base in real time to verify the order and provides real-time reminders or blocks any content that does not comply with the medical insurance fund payment regulations.

[0008] The online monitoring system generates an order information QR code through the medical insurance order. The order information QR code is transmitted between related systems. Pharmacy staff use the order information QR code to complete the pricing, reimbursement, and receipt of payment information in sequence.

[0009] The online monitoring system synchronously transmits pharmacy order data to the medical insurance department, enabling control over the source of prescriptions, the prescription process, the billing results, and the integration of all data.

[0010] Preferably, importing the pharmacy's inventory into the online monitoring system includes: obtaining product information from the pharmacy's inventory, including at least the product name, specifications, manufacturer, price, and inventory quantity; performing format conversion and standardization on the product information to make it conform to the data format requirements of the online monitoring system; importing the processed product information into the online monitoring system and establishing a unique correspondence between it and the actual products in the pharmacy.

[0011] Preferably, the online monitoring system covers all medical insurance reimbursement methods in the daily operation of pharmacies, including: supporting medical insurance order initiation for counter sales, supporting medical insurance order initiation for online drug purchases, and supporting medical insurance order initiation 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 monitoring system.

[0012] Preferably, the medical insurance knowledge base includes at least the medical insurance drug catalog, the medical insurance treatment item catalog, and the medical insurance service facility standards; the rule base includes at least the medical insurance fund payment rules, the medical insurance reimbursement ratio rules, and the medical insurance drug dosage rules; when the online monitoring system calls the medical insurance knowledge base and the rule base to perform real-time verification of the opened orders, the verification is performed in sequence according to the preset verification priority order.

[0013] More preferably, when performing real-time verification of the opened orders, the amount payable by the medical insurance fund is calculated based on the following formula:

[0014] ;

[0015] in, This indicates the amount that the medical insurance fund can cover; Indicates the type and quantity of goods or services in the order; Indicates the first in the order The quantity of a type of good or service; Indicates the first in the order The unit price of a commodity or service; Indicates the first in the order The corresponding medical insurance reimbursement ratio for this type of product or service ; Indicates the first in the order The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service meets the medical insurance payment regulations ,otherwise .

[0016] Furthermore, when the verification process reveals that an order contains content that does not comply with the regulations for medical insurance fund payment, the violation risk coefficient is calculated based on the following formula:

[0017] ;

[0018] in, Indicates the risk factor for violations. ; This indicates the types and quantities of goods or services in the order that do not comply with the regulations for payment by the medical insurance fund. This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The quantity of a type of good or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The unit price of a commodity or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The medical insurance reimbursement ratio for a particular product or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service does not comply with medical insurance payment regulations ; Indicates the type and quantity of goods or services in the order; Indicates the first in the order The quantity of a type of good or service; Indicates the first in the order The unit price of a commodity or service; when When the preset threshold is exceeded, the online monitoring system will intercept the data in real time.

[0019] Furthermore, when the online monitoring system performs real-time verification of orders, it also assesses the overall compliance of the orders based on the following formula:

[0020] ;

[0021] in, This indicates the overall compliance coefficient of the order. ; This indicates the number of prescription-related verification items involved in the order; Indicates the first The weights of each prescription-related validation item, ,and ; Indicates the first The compliance status indicator for each prescription-related verification item, when the first... When each prescription-related verification item meets the requirements , otherwise ; and respectively represent the medical insurance fund payment compliance weight and the prescription compliance weight, , and , .

[0022] Further preferably, the order information two-dimensional code contains order number, pharmacy identification, insured person information, commodity or service information, medical insurance fund payment information; the association system includes a pharmacy cash register system, a medical insurance settlement system, and a medical insurance supervision system; when the order information two-dimensional code is transmitted between the association systems, it is encrypted by an encryption algorithm to ensure data transmission security.

[0023] 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: storing the order data according to a preset time period; based on big data analysis technology, statistically analyzing the order data to generate a medical insurance fund usage report and a violation behavior analysis report; feeding back the analysis results to the medical insurance department to provide data support for medical insurance policy adjustment and supervision decision-making.

[0024] Further preferably, the online supervision system supports interfacing with an internet medical institution that meets the requirements of medical insurance management, receives a follow-up prescription issued by the internet medical institution, and performs compliance verification on the follow-up prescription; 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.

[0025] Technical effects:

[0026] The technical solution provided by the application effectively solves the problem that the medical insurance fund cannot be supervised in advance and in the process in the background technology. The creativity lies in constructing a unified sales portal and a data closed-loop supervision mode. The pharmacy can only initiate a medical insurance order through the online supervision system. The system calls the knowledge base and the rule base for verification in real time, and reminds or intercepts the irregular content in real time. At the same time, the whole process of ordering is controlled and data is integrated and transmitted, which not only moves the supervision link forward, prevents and controls violations in time during the reimbursement process, and reduces fund losses, but also reduces the interference with the operation of the pharmacy, ensures the safety of the medical insurance fund while meeting the operation needs of the pharmacy, and significantly improves the supervision efficiency and quality. BRIEF DESCRIPTION OF DRAWINGS

[0027] Figure 1 is a method flowchart of online supervision of medical insurance designated retail pharmacies for irregular use of medical insurance funds. DETAILED DESCRIPTION

[0028] In order to make the purposes, technical solutions and advantages of the present application clearer, the present application will be further described in detail below with reference to the accompanying drawings and examples. It should be understood that the specific examples described herein are only used to explain the present application and do not limit the present application.

[0029] Please refer to Figure 1 , such as the traditional technical solutions have the following technical problems: the existing centralized deployment of cloud MIS system solution has many problems, such as interference with the operation of drugstores, especially cross-regional chain drugstores; unable to check the compliance of the prescription, cannot effectively control the non-compliant reimbursement behavior; cannot access the convenient recheck prescription service; and can only extract data for post-checking, cannot realize online interception or reminder of violation during the reimbursement process. Based on this, the present embodiment proposes a method for online monitoring of the illegal use of medical insurance fund by medical insurance designated retail drugstores, comprising:

[0030] Importing the drugstore inventory into the online monitoring system as the basic data of goods in the drugstore in the online monitoring system;

[0031] Limiting the drugstore to only initiate medical insurance orders through the online monitoring system when conducting sales activities, and the medical insurance order initiation mode of the online monitoring system covers all medical insurance reimbursement modes in the daily operation of the drugstore;

[0032] During the order initiation process of the drugstore through the online monitoring system, the online monitoring system calls the built-in medical insurance knowledge base and rule base in real time to check the order in real time, and reminds or intercepts the content that does not comply with the medical insurance fund payment regulations in real time;

[0033] The online monitoring system generates an order information two-dimensional code through the medical insurance order, and the order information two-dimensional code is transmitted between related systems. The drugstore staff completes the pricing, reimbursement and charge information return work according to the order information two-dimensional code;

[0034] The online monitoring system synchronously transmits the drugstore order data to the medical insurance department to realize the control of the order source, the order process, the charge result and the integration of the full amount of data.

[0035] It is worth mentioning that: the embodiment constructs the core framework of the online supervision method of the medical insurance designated retail pharmacy for irregular use of medical insurance fund. First, the drug store inventory is imported into the online supervision system to provide basic data for subsequent supervision; then, the drug store sales behavior can only be initiated through the system to realize the unification of the sales entrance; in the order initiation process, the medical insurance knowledge base and rule base are called in real time for verification, and the irregular content is reminded or intercepted; the order information two-dimensional code is generated and transmitted to the association system to complete the pricing, reimbursement and other processes; finally, the order data is synchronized to the medical insurance department to achieve the control of the order source, process and result and the integration of full data. The whole process forms a closed loop to ensure the standardization and supervision of the use of medical insurance fund.

[0036] The technical effects achieved by the above embodiment include: by unifying the sales entrance and data, the interference with the operation of the drug store is reduced, especially for the drug stores with their own chain centralized deployment of cloud MIS system, without changing the internal management system, the operation cost is reduced. The pre and in-process supervision of the use of medical insurance fund is realized, compared with the post supervision of the existing scheme, the irregular behavior can be found and prevented in time, and the economic loss of the drug store caused by the medical insurance irregularity is effectively reduced. Through the supervision of the prescription and the access to the convenient recheck prescription service, the medical convenience of the insured people is improved, and the safety of the medical insurance fund is fully guaranteed, realizing the efficiency and accuracy of the medical insurance supervision.

[0037] The traditional technical scheme has the following technical problems: due to the differences in the data formats of the inventory of different drug stores, if the online supervision system is directly imported, it may cause problems such as data recognition, error reading or information confusion, affecting the normal operation and supervision accuracy of the supervision system. In addition, if the accurate correspondence of the goods cannot be established, misjudgment or omission may occur in the order verification process, which cannot effectively supervise the use of medical insurance fund. Based on this, the drug store inventory is imported into the online supervision system, including: obtaining the goods information in the drug store inventory, the goods information at least including the goods name, specification, manufacturer, price, inventory quantity; the goods information is subjected to format conversion and standardization processing to meet the data format requirements of the online supervision system; the processed goods information is imported into the online supervision system, and the unique correspondence with the actual goods of the drug store is established.

[0038] The embodiment solves the problems of data compatibility and accuracy by standardizing the data import process.

[0039] It is worth mentioning that: the embodiment further refines the above-mentioned, the operation process of importing the pharmacy inventory into the online supervision system. First, the information of the goods in the pharmacy inventory is obtained, including the name, specification, manufacturer, price, and inventory quantity of the goods; then the information is format-converted and standardized to meet the data format requirements of the online supervision system, ensuring the consistency and compatibility of the data; finally, the processed goods information is imported into the system, and a unique correspondence with the actual goods of the pharmacy is established, providing accurate data basis for subsequent order verification and supervision.

[0040] The technical effects achieved by the above embodiments include: after format conversion and standardization, the online supervision system can accurately read and process the goods information of the pharmacy, avoiding system failure or data errors caused by data format problems. Establishing a unique correspondence ensures that the system can accurately match the goods information with the medical insurance regulations during order verification, improving the accuracy and reliability of the verification. Thus, the supervision system can more accurately determine whether the order meets the medical insurance fund payment regulations, effectively reducing misjudgment and omission, further protecting the safety of medical insurance funds, and also providing accurate data support for pharmacies and medical insurance departments, facilitating subsequent data analysis and decision-making.

[0041] The 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 cannot be fully covered, there may be supervision 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 non-standard order information and inconsistent audit standards under different methods, affecting the efficiency and accuracy of medical insurance fund supervision. Based on this, the medical insurance order initiation method of the online supervision system covers all medical insurance reimbursement methods in the daily operation of the pharmacy, specifically including: supporting counter sales medical insurance order initiation, supporting online drug purchase medical insurance order initiation, and supporting medical insurance order initiation for prescriptions from off-site medical institutions; and each medical insurance order initiation method needs to complete order information input, review, and submission operations in the online supervision system.

[0042] It is worth mentioning that: the embodiment specifies that the medical insurance order initiation method of the online supervision system covers all medical insurance reimbursement methods in the daily operation of the pharmacy, specifically including counter sales medical insurance order initiation, online drug purchase medical insurance order initiation, and prescription medical insurance order initiation from off-site medical institutions. And it is stipulated that each initiation method needs to complete order information input, review, and submission operations in the system, ensuring that the initiation of all medical insurance orders is carried out under a unified supervision process, and effective supervision can be achieved regardless of the sales scenario.

[0043] The technical effects achieved by the above embodiment include: comprehensively covering various medical insurance order initiation modes, ensuring that each link of medical insurance fund use is under supervision, eliminating supervision blind spots, and effectively preventing irregular behaviors from escaping supervision through special sales scenarios. The unified order initiation operation process ensures the standardization of order information and the consistency of audit standards, improving the efficiency and accuracy of the supervision system in processing orders. This allows the medical insurance department to more comprehensively and accurately grasp the use of medical insurance funds, timely detect and handle irregular behaviors, and also facilitates pharmacies to operate according to uniform standards, reducing risks caused by non-standard operations.

[0044] The traditional technical solution has the following technical problems: medical insurance policies and regulations involve many aspects and are relatively complex. Without a clear knowledge base and rule base, the supervision system cannot accurately determine whether the order meets the medical insurance fund payment regulations. In addition, if there is no priority order in the verification process, it may lead to low verification efficiency, and even important issues may be overlooked. Therefore, the medical insurance knowledge base at least includes the medical insurance drug directory, the medical insurance diagnosis and treatment item directory, and the medical insurance service facility standard; the rule base at least includes the medical insurance fund payment rule, the medical insurance reimbursement ratio rule, and the medical insurance drug dosage rule; and when the online supervision system calls the medical insurance knowledge base and rule base to perform real-time verification on the order, the verification is performed in the preset verification priority order.

[0045] It is worth mentioning that: the embodiment details the content of the medical insurance knowledge base and the rule base. The medical insurance knowledge base includes the medical insurance drug directory, the medical insurance diagnosis and treatment item directory, and the medical insurance service facility standard. The rule base includes the medical insurance fund payment rule, the medical insurance reimbursement ratio rule, and the medical insurance drug dosage rule. At the same time, it is specified that when the online supervision system calls these bases to perform real-time verification on the order, the verification is performed in the preset verification priority order, ensuring the scientificity and orderliness of the verification process.

[0046] The technical effects achieved by the above embodiment include: the clear and explicit medical insurance knowledge base and rule base provide accurate verification basis for the online supervision system, enabling the system to accurately judge the order according to medical insurance policies and regulations, improving the accuracy and standardization of supervision. The preset verification priority order ensures that the system can prioritize checking key and important verification items when processing orders, improving verification efficiency and timely detecting and handling possible irregularities. This avoids the situation where irregularities are not detected in time due to chaotic verification or omission of important items, further ensuring the safe and reasonable use of medical insurance funds.

[0047] Traditional technical solutions suffer from the following problems: In the process of medical insurance fund payment, traditional calculation methods may not be accurate enough, easily leading to overpayment or underpayment, resulting in the unreasonable use of medical insurance funds. Furthermore, the lack of a scientific calculation formula makes it difficult to fully consider the impact of various factors in an order on medical insurance fund payments, and thus cannot accurately determine the rationality of medical insurance fund payments. Therefore, when performing real-time verification of opened orders, the amount payable by the medical insurance fund is calculated based on the following formula:

[0048] ;

[0049] in, This indicates the amount that the medical insurance fund can cover; Indicates the type and quantity of goods or services in the order; Indicates the first in the order The quantity of a type of good or service; Indicates the first in the order The unit price of a commodity or service; Indicates the first in the order The corresponding medical insurance reimbursement ratio for this type of product or service ; Indicates the first in the order The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service meets the medical insurance payment regulations ,otherwise .

[0050] In the technical solution for online monitoring of the misuse of medical insurance funds by designated medical insurance retail pharmacies, this formula is used to calculate the amount that the medical insurance fund can cover. Among them, the formula contains This indicates the quantity and variety of goods or services in the order. It's a fundamental parameter that defines the scope of the calculation and clarifies how many different goods or services in the order need to be comprehensively considered. For example, if a medical insurance order includes cold medicine, fever reducer, and band-aids, then... The value is . The first in the representative order The quantity of a particular good or service reflects the actual number of each item or service traded in that order. For example, in the order above, cold medicine was purchased... So, regarding the product of cold medicine, (Assuming the cold medicine is number one) The quantity of a particular commodity directly affects the amount of medical insurance fund payment for that commodity. It is the first in the order The unit price of a good or service is a key factor in calculating the total price. Unit prices vary significantly between different goods or services and are related to quantity. Multiply these to get the original price of each good or service without considering medical insurance reimbursement. For example, the unit price of a box of cold medicine is... Yuan, that is Yuan. Indicates the first in the order The corresponding medical insurance reimbursement ratio for this type of product or service This parameter reflects the degree of reimbursement support provided by medical insurance policies for different goods or services. For example, the reimbursement rate for a certain drug is... This means that the cost of the drug It can be paid for by the medical insurance fund. The value is determined based on medical insurance policies and the attributes of the goods or services themselves. For the first in the order The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service meets the medical insurance payment regulations ,otherwise It acts as a filter, ensuring that only goods or services meeting the eligibility criteria for medical insurance coverage are included in the calculation of the reimbursement amount from the medical insurance fund. For example, if a certain health supplement is not covered by medical insurance, then for that health supplement... The corresponding costs will not be included in the calculation of the amount payable by the medical insurance fund. The entire formula comprehensively calculates the quantity, unit price, medical insurance reimbursement ratio, and payment status of each product or service in the order, and sums up the payable amounts corresponding to the products 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 affecting medical insurance fund payments. Compared with traditional simple estimation methods, it can more accurately determine the amount that the medical insurance fund should actually pay, effectively avoiding overpayment or underpayment, and providing a scientific calculation basis for the rational use and precise supervision of medical insurance funds.

[0051] It is worth mentioning that this embodiment introduces a formula when performing real-time order verification. Calculate the amount that can be paid by the medical insurance fund. Among them, This indicates the amount that the medical insurance fund can cover. Indicates the type and quantity of goods or services in the order. Indicates the first The quantity of a type of goods or services Indicates the first The unit price of a commodity or service Indicates the first The corresponding medical insurance reimbursement ratio for this type of product or service Indicates the first This is an indicator of the medical insurance payment status for a particular product or service. By comprehensively considering various key factors of the product or service in the order, this formula accurately calculates the amount that the medical insurance fund can cover.

[0052] The technical effects achieved by the above embodiments 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, it greatly improves the accuracy of the calculation, avoids unreasonable payments by 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 both parties to verify and manage the payment of medical insurance funds, and reducing disputes and risks of violations caused by problems in calculating payment amounts.

[0053] Traditional technical solutions suffer from the following problems: merely determining whether an order contains content that violates medical insurance fund payment regulations cannot accurately assess the severity and risk of the violation, making it difficult to determine whether immediate interception measures are necessary. Furthermore, the lack of quantifiable violation risk assessment standards may lead to inconsistencies in handling violations by different regulatory personnel, affecting the consistency and effectiveness of supervision. Therefore, when verification reveals content in an order that violates medical insurance fund payment regulations, a violation risk coefficient is calculated based on the following formula:

[0054] ;

[0055] in, Indicates the risk factor for violations. ; This indicates the types and quantities of goods or services in the order that do not comply with the regulations for payment by the medical insurance fund. This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The quantity of a type of good or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The unit price of a commodity or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The medical insurance reimbursement ratio for a particular product or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service does not comply with medical insurance payment regulations ; Indicates the type and quantity of goods or services in the order; Indicates the first in the order The quantity of a type of good or service; Indicates the first in the order The unit price of a commodity or service; when When the preset threshold is exceeded, the online monitoring system will intercept the data in real time.

[0056] This formula is used to calculate the risk coefficient of violation. In the process of supervising medical insurance funds, it helps determine the degree of risk of violations when an order contains content that does not comply with medical insurance fund payment regulations. The formula... This indicates the number of non-compliant goods or services in an order, clarifying the range of potentially non-compliant items. For example, if an order contains two items that do not comply with medical insurance reimbursement regulations, then... . , , , These correspond to the quantity, unit price, reimbursement ratio, and payment status of goods or services that do not comply with regulations. Their meanings are similar to the corresponding parameters in the formula for the amount that can be paid by the medical insurance fund, but here the focus is on the non-compliant parts. This reflects the actual number of transactions involving the non-compliant goods or services; the larger the number, the greater the potential impact on the amount of the violation. It refers to the unit price of the non-compliant goods or services; the higher the unit price, the greater the risk of non-compliance. In this item, Originally it was a reimbursement ratio, This emphasizes the percentage of expenses not reimbursed according to regulations in cases of violations, such as the normal reimbursement percentage being... If a violation occurs , indicating that there is The fees charged may be subject to regulatory risks. In the middle, because This indicates the payment status identifier; when it does not meet the requirements... ,so This ensures that only non-compliant portions are included in the violation risk calculation. (Mellow part) This involves summing up the quantities, unit prices, violation rates, and violation labels of all non-compliant goods or services to obtain the total potential risk amount for the non-compliant portion of the order. The denominator is... This 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 is This indicates that the higher the proportion of the non-compliant portion of an order to the total order amount, the higher the risk of non-compliance. The closer the value is The lower the risk of violation, the better. When the threshold is exceeded, the online monitoring system will intercept the order in real time. This quantitative risk assessment method enables the monitoring system to more objectively and accurately judge the degree of risk of the order's violation, avoiding the subjectivity and uncertainty of human judgment, achieving accurate identification and timely intervention of violations, effectively protecting the safety of the medical insurance fund and preventing the medical insurance fund from suffering losses due to violations.

[0057] It is worth mentioning that, based on the above embodiments, when the verification finds that the order contains content that does not comply with the regulations for medical insurance fund payment, the formula is used. Calculate the violation risk coefficient. Among them, Indicates the risk factor for violations. This indicates the quantity of goods or services that do not comply with regulations. , , , These correspond to the quantity, unit price, reimbursement ratio, and payment status of goods or services that do not comply with the regulations. , , The meaning is the same as the formula for calculating the amount that can be paid by the medical insurance fund. When When a preset threshold is exceeded, the online monitoring system will intercept the violation in real time. This formula quantifies the risk of violations, enabling timely intervention in such behavior.

[0058] The technical effects achieved by the above embodiments include: the formula quantifies various factors affecting non-compliant parts of an order to obtain an accurate violation risk coefficient, which intuitively reflects the severity and risk of the violation. When the violation risk coefficient exceeds a preset threshold, the system automatically intercepts the violation in real time, achieving precise intervention and preventing greater losses. Simultaneously, the unified violation risk assessment standard ensures consistency and fairness in supervision, improves the efficiency and authority of supervision, effectively safeguards the security of the medical insurance fund, and reduces illegal expenditures from the medical insurance fund.

[0059] Traditional technical solutions suffer from the following problems: previous verification methods primarily focused on medical insurance fund payments, lacking comprehensive consideration of prescription compliance, which is equally crucial for the rational use of medical insurance funds. Failure to fully assess order compliance may overlook potential violations, leading to unreasonable expenditures of medical insurance funds. Therefore, the online monitoring system, when performing real-time order verification, also assesses the overall compliance of the order based on the following formula:

[0060] ;

[0061] wherein, represents the order overall compliance coefficient, ; represents the number of prescription-related check items involved in the order; represents the weight of the th prescription-related check item, , and ; represents the compliance status identifier of the th prescription-related check item, when the th prescription-related check item meets the requirements , otherwise ; and respectively represent the medical insurance fund payment compliance weight and the prescription compliance weight, , and , .

[0062] The formula is used to evaluate the order overall compliance coefficient , which comprehensively considers the medical insurance fund payment compliance and the prescription compliance two important aspects. In the formula, this part, related to the idea of the formula of the medical insurance fund payable amount, the numerator is the medical insurance fund payable amount calculated according to the medical insurance regulations, and the denominator is the original total amount of all goods or services in the order, and the ratio of the two reflects the compliance degree of the medical insurance fund payment part in the total amount of the order, which embodies the compliance of the order in the medical insurance fund payment. represents the medical insurance fund payment compliance weight, which is used to adjust the importance of the medical insurance fund payment compliance in the evaluation of the order overall compliance. For example, if the medical insurance fund payment compliance is considered more critical, the value of can be appropriately increased, so that the influence of the medical insurance fund payment compliance on the order overall compliance coefficient is greater. In the part, represents the number of prescription-related check items involved in the order, which clearly defines the number of items to be considered in the prescription compliance check. For example, a prescription may involve multiple check items such as drug compatibility contraindications, drug dosage rationality, and physician qualification for prescribing, and is the total number of these check items. represents the weight of the th prescription-related check item, , andDifferent prescription verification items have different importance for prescription compliance, and this difference is reflected by assigning different weights. For example, drug compatibility contraindication may be a very critical verification item, and a higher weight is assigned; while the prescription format specification is relatively less important, and a lower weight is assigned. represents the compliance state identifier of the th prescription-related verification item, and when the th prescription-related verification item is in compliance , otherwise , it is used to determine whether each prescription verification item is in compliance. The numerator is the sum of the weight of each prescription verification item multiplied by the compliance state identifier, and the comprehensive score of the prescription compliance is obtained; the denominator is used for normalization processing, so that the result of this part is 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. By weighting and summing the two parts of medical insurance fund payment compliance and prescription compliance according to their respective weights, the overall compliance coefficient of the order is obtained. When is lower than the preset compliance threshold, the system gives real-time reminders. This comprehensive evaluation method comprehensively considers the two key factors affecting order compliance, which can more comprehensively and accurately determine whether the order meets the medical insurance regulations, timely discover potential violation risks, avoid unreasonable use of medical insurance funds due to insufficient consideration of a single factor, and further improve the comprehensiveness and effectiveness of medical insurance fund supervision.

[0063] It is worth mentioning that: this embodiment further improves order verification, and on the basis of the above-mentioned embodiment, the overall compliance of the order is evaluated by the formula . Among them, represents the overall compliance coefficient of the order, , , , , have the same meaning as the calculation formula of the medical insurance fund payable amount, represents the number of prescription-related verification items, represents the weight of the th prescription-related verification item, represents the compliance state identifier of the th prescription-related verification item, and represent the medical insurance fund payment compliance weight and the prescription compliance weight, respectively. When When the compliance threshold is lower than the preset compliance threshold, the system provides real-time reminders. The order compliance is comprehensively evaluated by considering the medical insurance fund payment compliance and the prescription compliance.

[0064] The technical effects achieved by the above embodiments include that the formula combines the medical insurance fund payment compliance and the prescription compliance, and evaluates the overall compliance of the order through weight distribution, which can more comprehensively and accurately determine whether the order meets the medical insurance regulations. When the overall compliance coefficient of the order is lower than the preset threshold, the system timely provides reminders, so that the pharmacy and the medical insurance department can timely discover potential risks of violation and take corresponding measures for adjustment and processing. The unreasonable use of medical insurance fund caused by non-compliant prescriptions and other factors is effectively avoided, the supervision of the medical insurance fund is further strengthened, and the safety and rationality of the use of the medical insurance fund are improved.

[0065] The traditional technical solutions have the following technical problems: the order information involves important information such as pharmacies, insured persons, and medical insurance funds. If the information is leaked or tampered with during transmission, it may cause serious problems such as loss of medical insurance funds and leakage of insured person information. Moreover, data interaction between different related systems needs to ensure the accuracy and consistency of the information, otherwise it will affect the normal operation of the medical insurance reimbursement and supervision process. Based on this, the order information two-dimensional code contains order number, pharmacy identifier, insured person information, commodity or service information, and medical insurance fund payment information; the related systems include pharmacy cash register systems, medical insurance settlement systems, and medical insurance supervision systems; when the order information two-dimensional code is transmitted between the related systems, it is encrypted by an encryption algorithm to ensure the safety of data transmission.

[0066] It is worth mentioning that: the order information two-dimensional code contains order number, pharmacy identifier, insured person information, commodity or service information, and medical insurance fund payment information. At the same time, it is pointed out that the related systems include pharmacy cash register systems, medical insurance settlement systems, and medical insurance supervision systems, and it is stipulated that the order information two-dimensional code is encrypted by an encryption algorithm when it is transmitted between the related systems to ensure the safety and integrity of the data during transmission.

[0067] The technical effects achieved by the above embodiments include: the contents contained in the order information two-dimensional code are specified in detail to ensure the integrity and accuracy of data interaction between the related systems, so that each system can accurately obtain the required information and smoothly complete the pricing, reimbursement and other processes. The two-dimensional code is encrypted by an encryption algorithm, which effectively prevents the order information from being stolen or tampered with during transmission, ensures the safety of the data, and protects the privacy of the insured persons and the safety of the medical insurance fund. At the same time, the standardized data transmission method improves the efficiency and reliability of the medical insurance reimbursement and supervision process, and reduces the process delay and errors caused by data problems.

[0068] The traditional technical solution has the following technical problems: simply transmitting order data to the medical insurance department cannot fully utilize the value of the data. The medical insurance department needs to deeply analyze a large amount of order data to understand the use of medical insurance funds and the regularity of irregular behaviors, 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 accurately analyze. Based on this, the online supervision system synchronously transmits pharmacy order data to the medical insurance department, and further stores and analyzes the order data. Specifically, the order data is classified and stored according to a preset time period; based on big data analysis technology, the order data is statistically analyzed to generate medical insurance fund use situation reports and irregular behavior analysis reports; and the analysis results are fed back to the medical insurance department to provide data support for medical insurance policy adjustment and regulatory decision-making.

[0069] It is worth mentioning that after the order data is synchronously transmitted to the medical insurance department, the order data is further stored and analyzed. The order data is classified and stored according to a preset time period, facilitating data management and query; based on big data analysis technology, the order data is statistically analyzed to generate medical insurance fund use situation reports and irregular behavior analysis reports; and the analysis results are fed back to the medical insurance department to provide data support for medical insurance policy adjustment and regulatory decision-making.

[0070] The technical effects achieved by the above embodiments include: classified storage of order data enables the medical insurance department to quickly and accurately query and retrieve the required data, improving the efficiency of data management. The medical insurance fund use situation reports and irregular behavior analysis reports generated by using big data analysis technology provide comprehensive and in-depth data support for the medical insurance department, enabling it to clearly understand the use trend of medical insurance funds, the high-risk areas of irregular behaviors, and other information. Based on these analysis results, the medical insurance department can scientifically adjust medical insurance policies and optimize regulatory measures to improve the efficiency and security of medical insurance funds, and achieve scientific and intelligent medical insurance supervision.

[0071] The traditional technical solution has the following technical problems: with the development of internet medical treatment, online reconsultation prescription has gradually become a trend, but the traditional medical insurance supervision system cannot effectively connect with the reconsultation prescription of internet medical institutions, resulting in that the insured people cannot conveniently perform medical insurance reimbursement after online reconsultation, and there is also a problem of lack of prescription supervision.

[0072] The online supervision system supports connection with internet medical institutions that meet the requirements of medical insurance management, receives reconsultation prescriptions issued by the internet medical institutions, and performs compliance verification on the reconsultation prescriptions; when the reconsultation prescription passes the verification, a medical insurance order is initiated in the online supervision system based on the reconsultation prescription.

[0073] It is worth mentioning that the online supervision system supports the connection with the Internet medical institution that meets the medical insurance management requirements, receives the referral prescription issued by the Internet medical institution, and performs compliance verification on the referral prescription. When the referral prescription passes the verification, a medical insurance order is initiated in the online supervision system based on the prescription, realizing the effective connection of online referral prescription and medical insurance reimbursement.

[0074] The technical effects achieved by the above embodiments include: realizing the connection with the Internet medical institution, facilitating the insured people to perform online referral prescription and medical insurance reimbursement, improving the convenience and accessibility of medical treatment, and meeting the increasing medical service demand of the people. The compliance verification on the referral prescription ensures the standardization and legality of the online prescription, effectively prevents the illegal use of medical insurance fund through the online prescription, and guarantees the safety of the medical insurance fund. At the same time, the integration development of the Internet medical treatment and the medical insurance service is promoted, and the innovation and optimization of the medical service mode are promoted.

[0075] The above is only a preferred embodiment of the present application, and does not limit the present application in other forms. Any person skilled in the art can use the disclosed technical content to make changes or modifications to equivalent embodiments applied to other fields, but any simple modification, equivalent change and modification made on the basis of the technical essence of the present application to the above embodiments without departing from the technical solution content of the present application still belongs to the protection scope of the technical solution of the present application.

Claims

1. A method for online monitoring of the illegal use of medical insurance funds by designated medical insurance retail pharmacies, characterized in that, include: Import the pharmacy's inventory of goods into the online monitoring system, which will serve as the basic data for the pharmacy's goods in the online monitoring system. When conducting sales, pharmacies are restricted to initiating medical insurance orders only through the online monitoring system. The online monitoring system covers all medical insurance reimbursement methods used by pharmacies in their daily operations. During the process of a pharmacy initiating an order through the online monitoring system, the online monitoring system calls the built-in medical insurance knowledge base or rule base in real time to verify the order and provides real-time reminders or blocks any content that does not comply with the medical insurance fund payment regulations. The online monitoring system generates an order information QR code through the medical insurance order. The order information QR code is transmitted between related systems. Pharmacy staff use the order information QR code to complete the pricing, reimbursement, and receipt of payment information in sequence. The online monitoring system will synchronously transmit pharmacy order data to the medical insurance department to achieve control over the source of prescriptions, the process of prescriptions, the results of billing, and the integration of all data. When performing real-time verification of the opened orders, the amount payable by the medical insurance fund is calculated based on the following formula: ； in, This indicates the amount that the medical insurance fund can cover; Indicates the type and quantity of goods or services in the order; Indicates the first in the order The quantity of a type of good or service; Indicates the first in the order The unit price of a commodity or service; Indicates the first in the order The corresponding medical insurance reimbursement ratio for this type of product or service ; Indicates the first in the order The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service meets the medical insurance payment regulations ,otherwise When the verification process reveals that an order contains content that does not comply with the regulations for medical insurance fund payment, the violation risk coefficient is calculated based on the following formula: ； in, Indicates the risk factor for violations. ; This indicates the types and quantities of goods or services in the order that do not comply with the regulations for payment by the medical insurance fund. This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The quantity of a type of good or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The unit price of a commodity or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The medical insurance reimbursement ratio for a particular product or service; This indicates that the order does not comply with the regulations for payment by the medical insurance fund. The medical insurance payment status indicator for a certain type of goods or services, when the first When a product or service does not comply with medical insurance payment regulations ; Indicates the type and quantity of goods or services in the order; Indicates the first in the order The quantity of a type of good or service; Indicates the first in the order The unit price of a commodity or service; when When the preset threshold is exceeded, the online monitoring system will intercept the order in real time; when the online monitoring system verifies the order in real time, it will also evaluate the overall compliance of the order based on the following formula: ； in, This indicates the overall compliance coefficient of the order. ; This indicates the number of prescription-related verification items involved in the order; Indicates the first The weights of each prescription-related validation item, ,and ; Indicates the first The compliance status indicator for each prescription-related verification item, when the first... When each prescription-related verification item meets the requirements ,otherwise ; and These represent the weighting for compliance with medical insurance fund payments and the weighting for compliance with prescriptions, respectively. ,and , .

2. The method for online supervision of the illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1, characterized in that, The process of importing the pharmacy's inventory into the online monitoring system includes: acquiring product information from the pharmacy's inventory, including at least the product name, specifications, manufacturer, price, and inventory quantity; performing format conversion and standardization on the product information to make it conform to the data format requirements of the online monitoring system; importing the processed product information into the online monitoring system and establishing a unique correspondence between it and the actual products in the pharmacy.

3. The method for online supervision of the illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1, characterized in that, The online monitoring system covers all medical insurance reimbursement methods in the daily operation of pharmacies, including: supporting medical insurance order initiation for counter sales, supporting medical insurance order initiation for online drug purchases, and supporting medical insurance order initiation for prescriptions dispensed 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 monitoring system.

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

5. The method for online supervision of the illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1, 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 POS system, medical insurance settlement system, and 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.

6. The method for online supervision of the illegal use of medical insurance funds by designated medical insurance retail pharmacies according to claim 1, characterized in that, After transmitting pharmacy order data to the medical insurance department, the online monitoring system also stores and analyzes the order data. Specifically, this includes: classifying and storing the order data according to a preset time period; performing statistical analysis on the order data based on big data analysis technology to generate reports on the use of medical insurance funds and reports on violations; and feeding back the analysis results to the medical insurance department to provide data support for medical insurance policy adjustments and regulatory decisions.

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

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