A blockchain signature settlement method for DRG and DIP

Abstract

The application discloses a kind of DRG and DIP-oriented blockchain signature settlement method, specifically related to blockchain technical field, the application includes: hospital uploads medical record data and generates SM2 digital signature;Medical insurance bureau verifies signature and executes DRG / DIP grouping operation and generates medical insurance bureau signature;The grouping result and the signature of both parties are stored in chain and stored, and the settlement process is automatically triggered and the amount of money should be paid by smart contract;Hospital generates confirmation signature after confirmation and stores in chain;Medical insurance bureau executes fund allocation according to confirmation result and generates allocation signature and stores in chain, and finally form the complete signature chain covering whole process.This application also provides corresponding settlement system, through the synergistic effect of blockchain storage, smart contract automatic settlement and complete signature chain, it realizes that settlement data is not tamperable, whole process is traceable, multi-party trust is established, settlement is automated and dispute processing has basis, significantly improve the efficiency and credibility of medical insurance settlement.

Description

Technical Field

[0001] This invention relates to the field of blockchain technology, and more specifically, to a blockchain signature settlement method for DRGs and DIPs. Background Technology

[0002] With the deepening of medical reform, payment methods based on Diagnosis Related Groups (DRG) and Disease-Based Value (DIP) have been promoted nationwide.

[0003] However, the current settlement system between the medical insurance bureau and hospitals still has the following technical defects:

[0004] 1. Data is easily tampered with: Settlement data is stored in a centralized database, which is at risk of being tampered with internally or externally, and lacks a reliable audit basis.

[0005] 2. Lack of transparency in the process: There is a lack of unified visual traceability methods for each step of the settlement process, such as uploading medical records, grouping, calculation, confirmation, and payment, making it difficult to reconstruct the process when disputes occur.

[0006] 3. Lack of trust among multiple parties: Hospitals, medical insurance bureaus, and patients lack a common basis for trust in the settlement results, and mutual questioning occurs frequently.

[0007] 4. Low settlement efficiency: Relying on manual reconciliation and multi-level auditing, the settlement cycle is generally as long as 15-30 days, resulting in slow capital recovery.

[0008] 5. Signature silos: The signatures in existing electronic medical records and electronic prescriptions are single, independent signatures, which do not form a signature chain that runs through the entire process. Furthermore, after the grouping results are obtained, manual operation is required before the settlement process can begin, and it cannot be triggered automatically.

[0009] Therefore, there is an urgent need for a new settlement method that can solve the above-mentioned technical problems at the same time. Summary of the Invention

[0010] To achieve the above objectives, the present invention provides the following technical solution:

[0011] On the one hand, this invention provides a blockchain signature settlement method for DRGs and DIPs, comprising the following steps:

[0012] S1. Uploading Medical Record Data and Hospital Signature: The hospital uploads medical record data and uses the national cryptographic SM2 algorithm to generate a digital signature for the medical record data. The signature result is then sent to the medical insurance bureau system along with the medical record data.

[0013] S2. Grouping and Signing by the Medical Insurance Bureau: The Medical Insurance Bureau system receives the medical record data, verifies the hospital's signature, executes the DRG / DIP grouping algorithm to generate grouping results, and generates a digital signature for the Medical Insurance Bureau on the grouping results.

[0014] S3. Data upload and smart contract triggering: The grouping result, hospital signature and medical insurance bureau signature are sent to the blockchain node. After verifying the validity of the signature, the data hash is written into the block. The smart contract automatically detects the grouping result and triggers the settlement process.

[0015] S4. Smart contract execution settlement: The smart contract calculates the amount due according to the preset settlement rules, writes the settlement calculation process and results into the blockchain, and adds a timestamp;

[0016] S5. Hospital Confirmation Signature: The hospital queries and confirms the settlement result, generates a digital signature for the confirmation operation, and uploads it to the blockchain.

[0017] S6. Fund disbursement and disbursement signature: The medical insurance bureau system executes fund disbursement based on the confirmed settlement results, generates a digital signature for the disbursement instruction and uploads it to the blockchain;

[0018] S7. Formation of the full-process signature chain: The signatures of all key nodes form a complete signature chain, and any node can verify the integrity of the signature chain, realizing full-process traceability.

[0019] Preferably, the DRG / DIP grouping algorithm in step S2 includes: determining the MDC main classification based on the primary diagnosis, determining surgical or non-surgical grouping based on the surgical procedure, and determining the final grouping in combination with other diagnoses.

[0020] Preferably, the preset settlement rule calculation formula in step S4 is: Amount payable = Group weight × Rate; Medical insurance payment = Amount payable × Reimbursement ratio; Patient co-payment = Amount payable - Medical insurance payment.

[0021] Preferably, the method further includes a dispute resolution process: when a hospital disagrees with the settlement result, it can submit an appeal request and generate a signature on the blockchain; after review by the medical insurance bureau, a new settlement result is generated and both parties' signatures are uploaded to the blockchain; the signature chain can be used as arbitration evidence.

[0022] Preferably, the method further includes a batch settlement scenario: the hospital packages multiple medical records and generates digital signatures in batches; the medical insurance bureau performs batch grouping operations and signatures; blockchain nodes verify signatures in batches and trigger smart contracts for batch settlement; wherein, the batch signature verification adopts a parallel processing mechanism.

[0023] On the other hand, the present invention also provides a blockchain signature settlement system for DRGs and DIPs, used to implement the method described in any of the above-mentioned embodiments, comprising:

[0024] Data access layer: used to access medical record data uploaded from the hospital's HIS system and perform data standardization and format conversion;

[0025] Signature Service Layer: Used to generate and manage digital signatures of all participants, employing the national cryptographic SM2 algorithm and adding a timestamp;

[0026] Blockchain layer: Employs consortium blockchain technology for hash-based notarization of settlement data and storage of the complete signature chain;

[0027] Smart contract layer: Built-in contract engine and rule engine, used to automatically execute settlement rules and trigger settlement process;

[0028] Verification service layer: used to verify signatures and perform hash checks on data integrity.

[0029] Preferably, the consensus mechanism used in the blockchain layer is the Practical Byzantine Fault Tolerance (PBFT) algorithm.

[0030] Preferably, the timestamp used by the signature service layer comes from a trusted time source from the National Time Service Center.

[0031] The technical effects and advantages of this invention are as follows:

[0032] 1. This invention improves the credibility of all parties by putting the entire settlement process data on the blockchain and using the immutability of the blockchain to ensure data trustworthiness. Any tampering can be detected.

[0033] 2. This invention forms a complete signature chain by uploading all signatures of key nodes to the blockchain, achieving full traceability of the process. The signature chain can serve as credible evidence for dispute arbitration, solving the problem of difficulty in dispute resolution.

[0034] 3. This invention utilizes grouping results to automatically trigger smart contracts, thereby automating settlement, significantly reducing manual intervention, and shortening the settlement cycle from 15-30 days to 1-3 days.

[0035] 4. This invention supports batch signature generation and parallel verification, which significantly improves processing efficiency in batch settlement scenarios and meets the high-frequency settlement needs of medical insurance.

[0036] 5. This invention adopts the national cryptographic SM2 signature algorithm and trusted timestamp, which complies with the national cryptography law and medical insurance informatization compliance requirements, and supports comprehensive auditing. Attached Figure Description

[0037] Figure 1 This is a flowchart of the overall process of the method of the present invention.

[0038] Figure 2 This is a system architecture diagram of the present invention. Detailed Implementation

[0039] The technical solutions of the present invention will be clearly and completely described below with reference to the accompanying drawings in the embodiments of the present invention.

[0040] Example 1

[0041] Normal settlement process:

[0042] This embodiment provides a blockchain signature settlement method for DRG and DIP, which is applied to the entire process of a patient settling DRG after being discharged from a hospital.

[0043] Step 1: Upload medical record data and obtain hospital signature

[0044] After the patient's discharge, the hospital's HIS system automatically generated medical record data, including: patient information, admission and discharge dates, diagnosis information: primary diagnosis: acute myocardial infarction, surgical information: coronary artery stent implantation, and cost details: total 38,500 yuan. The hospital performed an SM2 digital signature on this medical record data, using the following algorithm: SM3 medical record data hash → SM2 hospital private key signature. The signature result, along with the medical record data, was sent to the medical insurance bureau system.

[0045] Step 2: Grouping calculation and signature by the Medical Insurance Bureau

[0046] After receiving the data, the medical insurance bureau system verifies the signature validity using the hospital's public key. Upon successful verification, the DRG grouping algorithm is executed: based on the primary diagnosis of "acute myocardial infarction," the MDC main classification is determined as a circulatory system disease; based on the surgical procedure "coronary artery stenting," a surgical group is determined; combined with other diagnoses, the final group code "DRG-FM19" is generated, indicating percutaneous coronary artery stenting with serious complications or comorbidities, with a corresponding weight of 3.5 and a premium rate of 10,000 yuan. The medical insurance bureau generates a digital signature for the grouping result.

[0047] Step 3: Data upload to the blockchain and smart contract triggering

[0048] The grouping results are encoded using FM19 with a weight of 3.5, and along with the hospital's signature and the medical insurance bureau's signature, are sent to the blockchain node. After the node verifies the validity of all signatures, it generates a data hash, writes it to a block, and attaches a trusted timestamp. The settlement smart contract deployed on the chain listens for new grouping results and automatically triggers the settlement process.

[0049] Step 4: Smart contract execution and settlement

[0050] The smart contract executes the calculation: Amount payable = Group weight × Fee rate = 3.5 × 10000 = 35000 yuan. Based on the preset reimbursement rate of 85%, the medical insurance payment is calculated to be 35000 × 85% = 29750 yuan, and the patient's out-of-pocket payment is 35000 - 29750 = 5250 yuan. A settlement result containing the calculation process is generated and written to the blockchain for record-keeping.

[0051] Step 5: Hospital confirmation signature

[0052] The hospital system retrieves the settlement results from the blockchain, confirms the amount, generates a hospital confirmation signature, and stores it on the blockchain.

[0053] Step 6: Fund Disbursement and Disbursement Signature

[0054] After the medical insurance bureau system detects the hospital's confirmation signature, it executes the fund disbursement operation, generates a disbursement signature for the disbursement instruction, and stores it on the blockchain.

[0055] Step 7: Complete signature chain formed

[0056] Thus, from medical record signatures, group signatures, settlement signatures, confirmation signatures to disbursement signatures, all key signature nodes form a complete and tamper-proof signature chain, which can be verified by any party, achieving full traceability.

[0057] Example 2: Dispute Resolution Process

[0058] This embodiment is basically the same as Embodiment 1, except for step 5: The hospital objects to the settlement result, believing that the group weight is too low and should actually be 4.0. At this time, the hospital refuses to confirm in the system and submits an appeal request and reasons, generating an appeal signature on the blockchain. After receiving the appeal, the Medical Insurance Bureau conducts a manual review, finds that the coding is incorrect, regenerates the correct group result, with a weight of 4.0 and both parties' signatures on the blockchain, and triggers the smart contract to re-settle. The amount due is 40,000 yuan, with medical insurance paying 34,000 yuan and the patient paying 6,000 yuan. After the hospital accepts the new result, the process continues. If the dispute still cannot be resolved, the arbitration institution can retrieve the complete signature chain on the blockchain as arbitration evidence.

[0059] Example 3: Batch Settlement Scenario

[0060] This embodiment is essentially the same as Embodiment 1, except for the processing mode. A top-tier hospital packages 50 patient medical records discharged that day, generates 50 digital signatures in batches, and sends them to the medical insurance bureau system all at once. The medical insurance bureau performs batch grouping operations and generates medical insurance bureau signatures in batches. After the data is uploaded to the blockchain in batches, the smart contract triggers 50 settlement processes in batches. In the signature verification stage, the system adopts a parallel processing mechanism and multi-threaded verification, reducing the overall processing time from 50 × 0.5 seconds = 25 seconds for serial verification to 3 seconds. The batch settlement results are uniformly returned to the hospital for confirmation.

[0061] Comparative Example 1

[0062] This comparison uses a traditional centralized medical insurance settlement system, lacking blockchain and smart contracts. After hospitals upload medical records, the medical insurance bureau manually reviews and groups them. The grouping results circulate through the internal system, and the settlement process is manually triggered. Hospitals obtain settlement statements via email or offline for confirmation, and the final payment is manually completed by the finance department. The entire process involves no data sharing, lacks transparency, has an average settlement cycle of 20 days, and has even resulted in disputes due to database tampering leading to incorrect settlement amounts; due to a lack of credible evidence, the process took three months to resolve.

[0063] Comparative Example 2

[0064] This comparison uses blockchain notarization but without automatic smart contract triggering. Data is stored on the blockchain, but manual intervention is still required after the grouping results are generated before the settlement process can begin. Furthermore, signatures are stored independently and no signature chain is formed. The settlement cycle is approximately 12 days.

[0065] Comparative Example 3

[0066] This comparison uses a smart contract-based automatic settlement method, but lacks a complete signature chain. The grouping results can automatically trigger settlement, but the signatures of each step are stored independently and not linked together. In the event of a dispute, it is impossible to provide evidence of the entire process. Dispute resolution still requires manual verification of multiple systems, which takes approximately 30 days.

[0067] Performance testing

[0068] Comparative tests were conducted on Examples 1-3 and Comparative Examples 1-3 above. Test conditions: simulating one month's settlement data between a municipal medical insurance bureau and 10 hospitals, totaling 5000 medical records. The test results are as follows:

[0069] Test metrics Example 1 Example 2 Example 3 Comparative Example 1 Comparative Example 2 Comparative Example 3 Average settlement cycle per transaction (days) 1.5 2.0 (including dispute resolution) 0.5 20 12 1 Data tampering detection rate (%) 100 100 5 100 100 100 End-to-end traceability (is it supported?) yes yes yes no no no Average dispute resolution time (days) — 3 — 45 25 30 Number of manual intervention steps 0 (Normal process) 1 (Review Process) 0 5 3 1 Batch processing time for 50 documents (seconds) — — 3 600 (labor) 120 (semi-automatic) —

[0070] As can be seen from the above data, Embodiments 1-3 of the present invention are significantly superior to the comparative embodiments in terms of settlement efficiency, data security, process transparency and dispute resolution capabilities.

[0071] The batch parallel verification mechanism in Example 3 greatly improves the processing efficiency in high-concurrency scenarios.

[0072] Comparative Example 1 has the worst performance across all metrics due to the lack of blockchain and smart contracts; Comparative Example 2, although it has on-chain evidence storage, lacks automatic triggering, resulting in low efficiency; Comparative Example 3, although it can automatically settle accounts, lacks a signature chain, making dispute resolution difficult.

[0073] This demonstrates that the present invention has achieved unexpected technical results through the collaborative mechanism of "blockchain notarization + automatic smart contract triggering + complete signature chain".

[0074] The above are all preferred embodiments of this application, and are not intended to limit the scope of protection of this application. Therefore, all equivalent changes made in accordance with the structure, shape and principle of this application should be covered within the scope of protection of this application.

Claims

1. A blockchain signature settlement method for DRG and DIP, characterized in that: Includes the following steps: S1. Uploading Medical Record Data and Hospital Signature: The hospital uploads medical record data and uses the national cryptographic SM2 algorithm to generate a digital signature for the medical record data. The signature result is then sent to the medical insurance bureau system along with the medical record data. S2. Grouping and Signing by the Medical Insurance Bureau: The Medical Insurance Bureau system receives the medical record data, verifies the hospital's signature, executes the DRG / DIP grouping algorithm to generate grouping results, and generates a digital signature for the Medical Insurance Bureau on the grouping results. S3. Data upload and smart contract triggering: The grouping result, hospital signature and medical insurance bureau signature are sent to the blockchain node. After verifying the validity of the signature, the data hash is written into the block. The smart contract automatically detects the grouping result and triggers the settlement process. S4. Smart contract execution settlement: The smart contract calculates the amount due according to the preset settlement rules, writes the settlement calculation process and results into the blockchain, and adds a timestamp; S5. Hospital Confirmation Signature: The hospital queries and confirms the settlement result, generates a digital signature for the confirmation operation, and uploads it to the blockchain. S6. Fund disbursement and disbursement signature: The medical insurance bureau system executes fund disbursement based on the confirmed settlement results, generates a digital signature for the disbursement instruction and uploads it to the blockchain; S7. Formation of the full-process signature chain: The signatures of all key nodes form a complete signature chain, and any node can verify the integrity of the signature chain, realizing full-process traceability.

2. The method according to claim 1, characterized in that: The DRG / DIP grouping algorithm in step S2 includes: determining the MDC main classification based on the primary diagnosis, determining surgical or non-surgical grouping based on the surgical procedure, and determining the final grouping in combination with other diagnoses.

3. The method according to claim 1, characterized in that: The preset settlement rule calculation formula in step S4 is as follows: Amount payable = Group weight × Rate; Medical insurance payment = Amount payable × Reimbursement ratio; Patient co-payment = Amount payable - Medical insurance payment.

4. The method according to claim 1, characterized in that: When a hospital disagrees with the settlement result, it can submit an appeal request and generate a signature on the blockchain; after review by the medical insurance bureau, a new settlement result and signatures from both parties will be generated and uploaded to the blockchain. A chain of signatures can be used as evidence in arbitration.

5. The method according to claim 1, characterized in that: The hospital packages multiple medical records into a single package and generates digital signatures in batches; the medical insurance bureau performs batch grouping operations and signatures; blockchain nodes verify signatures in batches and trigger smart contracts for batch settlement; among these, batch signature verification adopts a parallel processing mechanism.

6. A blockchain signature settlement system for DRG and DIP, used to implement the method described in any one of claims 1-5, characterized in that: include: Data access layer: used to access medical record data uploaded from the hospital's HIS system and perform data standardization and format conversion; Signature Service Layer: Used to generate and manage digital signatures of all participants, employing the national cryptographic SM2 algorithm and adding a timestamp; Blockchain layer: Employs consortium blockchain technology for hash-based notarization of settlement data and storage of the complete signature chain; Smart contract layer: Built-in contract engine and rule engine, used to automatically execute settlement rules and trigger settlement process; Verification service layer: used to verify signatures and perform hash checks on data integrity.

7. The system according to claim 6, characterized in that: The consensus mechanism used in the blockchain layer is the Practical Byzantine Fault Tolerance (PBFT) algorithm.

8. The system according to claim 6, characterized in that: The timestamps used in the signature service layer come from a trusted time source provided by the National Time Service Center.

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