Medical expense breakdown analysis device, medical expense breakdown analysis method, and medical expense breakdown analysis program

Abstract

Medical expenses are appropriately allocated for each illness or injury. [Solution] The system reads medical treatment codes (medical procedure codes, drug codes, specific equipment codes, etc.) from the medical claim summary information database, refers to master information to read disease name codes associated with the read medical treatment codes, selects disease name codes from the medical claim disease name information database that are associated with the read disease name codes, and outputs the disease name of the selected disease name code in the medical claim disease name information database and the medical expenses associated with the medical treatment codes read from the medical claim summary information database in association with each other. If there are medical treatments that are not associated with any of the disease name codes in the medical claim disease name information database, the medical expenses for those unrelated medical treatments are allocated to the disease names associated with medical expenses at a predetermined ratio.

Description

Technical Field

[0001] The present invention relates to a medical expense breakdown analysis device, a medical expense breakdown analysis method, and a medical expense breakdown analysis program.

Background Art

[0002] In order to construct and operate a health management promotion system, a medical record database based on actual medical records is used. The database is constructed for each healthcare provider using OCR conversion technology and a medical information database with information on paper receipts (headers, disease names, medical procedures). Such a medical record database accumulates the medical records of all subscribers over time for each insurer, enabling statistical analysis of data from various perspectives, such as insured persons and their families, medical institutions, and diseases. Therefore, a technology for providing medical expense statistical information as a health care service has been disclosed (Patent Document 1).

[0003] Also, a medical expense breakdown analysis device has been disclosed that can identify which diseases a plurality of drugs and medical procedures described on a receipt correspond to (Patent Document 2). The medical procedure code or drug code is read from the receipt description information, and the injury and disease name code associated with the same classification code as the medical procedure code or drug code is read from the master information. Then, the receipt description information is searched, and among the injury and disease name codes having the same receipt ID as the medical procedure code or drug code, those included in the injury and disease name code are selected. Further, the medical expenses associated with the medical procedure code or drug code are read from the receipt description information, and the read medical expenses are associated with the selected injury and disease name code and stored as injury and disease-related data.

Prior Art Documents

Patent Documents

[0004]

Patent Document 1

Patent Document 2

[0005] However, with conventional technology, when medical treatment includes services that cannot be assigned to any specific disease or injury, it is not possible to allocate the medical expenses associated with such services to the appropriate disease or injury. Therefore, there is a need for a medical expense decomposition analysis device, a medical expense decomposition analysis method, and a medical expense decomposition analysis program that can more appropriately allocate medical expenses that could not be allocated with conventional technology. [Means for solving the problem]

[0006] One aspect of the present invention is a medical expense breakdown and analysis device that can access a medical claim disease name information database which associates disease names recorded on medical claims with disease name codes for said disease names; a medical claim summary information database which associates medical treatment content recorded on medical claims with medical treatment content codes indicating said medical treatment content and the medical expenses for said medical treatment content; and master information which associates the disease name codes with the medical treatment content codes; reads medical treatment content codes indicating medical treatment content from the medical claim summary information database, refers to the master information, reads disease name codes associated with the read medical treatment content codes, and accesses the medical claim disease name information database This medical expense decomposition and analysis device is characterized by selecting a disease name code from among the disease name codes included in the database that is associated with the read disease name code, outputting the disease name of the selected disease name code in the medical claim disease name information database and the medical expenses associated with the medical treatment content code read in the medical claim summary information database, and, by referring to the master information, if there are medical treatment contents that are not associated with any of the disease name codes included in the medical claim disease name information database, allocating the medical expenses of the unassociated medical treatment contents to the disease names associated with medical expenses at a predetermined ratio.

[0007] Here, the predetermined ratio is preferably the ratio of medical expenses for each disease name, which is obtained by allocating the medical expenses for treatment content associated with any disease name to each disease name out of the total medical expenses in the claims summary information database.

[0008] Furthermore, if the medical treatment details included in the aforementioned claims summary information database are for a specified medical treatment, it is preferable to associate the medical expenses for that treatment with the suspected disease name.

[0009] Furthermore, the aforementioned prescribed medical treatment content is preferably related to an initial consultation, examination, or diagnostic imaging.

[0010] Furthermore, it is preferable to associate the medical expenses for a prescribed medical treatment with the name of the illness or injury, based on the start date of treatment for the illness or injury and the number of times the initial consultation fee has been charged. It is also preferable that the prescribed medical treatment refers to the initial consultation.

[0011] Furthermore, if the medical treatment details included in the aforementioned claims summary information database are specified medical treatment details, it is preferable to associate the medical expenses for said medical treatment details only with the primary disease name. Also, it is preferable that the specified medical treatment details relate to medical management.

[0012] Furthermore, it is preferable to change the order of the association process between medical expenses and disease names for each medical treatment identification in the medical treatment details database.

[0013] Another aspect of the present invention is a medical expense breakdown analysis program comprising: a medical claim disease name information database that associates disease names recorded on medical claims with disease name codes for said disease names; a medical claim summary information database that associates medical treatment content recorded on medical claims with medical treatment content codes indicating said medical treatment content and the medical expenses for said medical treatment content; master information that associates the disease name codes with the medical treatment content codes; and a computer that can access the medical claim summary information database to read medical treatment content codes indicating medical treatment content, refer to the master information to read disease name codes associated with the read medical treatment content codes, and include in the medical claim disease name information database This medical expense decomposition analysis program is characterized by selecting a disease name code from among the read disease name codes and associating the disease name of the selected disease name code with the medical expense associated with the medical treatment content code read from the medical claim summary information database and outputting the result; and, if there is a medical treatment content that is not associated with any of the disease name codes included in the medical claim disease name information database by referring to the master information, the program executes a process to allocate the medical expenses of the unassociated medical treatment content to the disease name associated with the medical expense at a predetermined ratio.

[0014] Another aspect of the present invention is a medical expense decomposition analysis method, comprising: a medical claim disease name information database that associates disease names recorded on medical claims with disease name codes for said disease names; a medical claim summary information database that associates medical treatment content recorded on medical claims with medical treatment content codes indicating said medical treatment content and the medical expenses for said medical treatment content; and master information that associates the disease name codes with the medical treatment content codes; a computer that can access these; reads medical treatment content codes indicating medical treatment content from the medical claim summary information database; refers to the master information; reads disease name codes associated with the read medical treatment content codes; and includes in the medical claim disease name information database This medical expense decomposition analysis method is characterized by selecting a disease name code associated with the read disease name code from among the available disease name codes, performing a process to output the disease name of the selected disease name code in the medical claim disease name information database and the medical expenses associated with the medical treatment content code read in the medical claim summary information database, and, if there are medical treatment contents that are not associated with any of the disease name codes included in the medical claim disease name information database by referring to the master information, performing a process to allocate the medical expenses of the unassociated medical treatment contents to the disease names associated with medical expenses at a predetermined ratio. [Effects of the Invention]

[0015] According to the present invention, medical expenses, which were not properly allocated in the prior art, can be appropriately allocated to each illness or injury. Other objects of embodiments of the present invention will become apparent by referring to the entire specification. [Brief explanation of the drawing]

[0016] [Figure 1] This figure shows the configuration of a medical expense breakdown analysis device according to an embodiment of the present invention. [Figure 2] This figure shows an example of a medical fee statement. [Figure 3] This is a diagram showing an example of a prescription payment statement. [Figure 4]It is a diagram showing an example of a receipt disease name information database in an embodiment of the present invention. [Figure 5] It is a diagram showing an example of a receipt summary information database in an embodiment of the present invention. [Figure 6] It is a diagram showing a medical treatment identification code (a code for identifying a medical act). [Figure 7] It is a diagram showing the configuration of master information in an embodiment of the present invention. [Figure 8] It is a diagram showing an example of a disease name master in an embodiment of the present invention. [Figure 9] It is a diagram showing an example of a medical treatment master in an embodiment of the present invention. [Figure 10] It is a diagram showing an example of disease-related data in an embodiment of the present invention. [Figure 11] It is a diagram showing an example of the configuration of drug data in an embodiment of the present invention. [Figure 12] It is a diagram showing an example of a drug master in an embodiment of the present invention. [Figure 13] It is a diagram showing an example of a symptom master in an embodiment of the present invention. [Figure 14] It is a diagram showing an example of disease-related data in an embodiment of the present invention. [Figure 15] It is a diagram showing an example of a medical treatment-to-medical treatment master in an embodiment of the present invention. [Figure 16] It is a diagram showing an example of a drug-to-medical treatment master in an embodiment of the present invention. [Figure 17] It is a diagram showing an example of a receipt including specific equipment in an embodiment of the present invention. [Figure 18] It is a diagram showing an example of a receipt disease name information database in an embodiment of the present invention. [Figure 19] It is a diagram showing an example of a receipt summary information database in an embodiment of the present invention. [Figure 20] It is a diagram showing an example of disease-related data in an embodiment of the present invention. [Figure 21]This figure shows an example of a medical claim form including specific equipment according to an embodiment of the present invention. [Figure 22] This figure shows an example of a medical claim form including specific equipment according to an embodiment of the present invention. [Figure 23] This figure shows an example of a medical claim form including specific equipment according to an embodiment of the present invention. [Figure 24] This figure shows an example of a medical equipment-to-medical procedure master in an embodiment of the present invention. [Figure 25] This figure shows an example of a medical claim form including specific equipment according to an embodiment of the present invention. [Figure 26] This figure shows an example of a medical claim form including specific equipment according to an embodiment of the present invention. [Figure 27] This figure illustrates the relationship between the start date of medical treatment and the treatment date in a medical claim form according to an embodiment of the present invention. [Figure 28] This figure shows an example of a medical claim form including an initial consultation fee in an embodiment of the present invention. [Figure 29] This figure shows an example of injury / illness-related data in an embodiment of the present invention. [Figure 30] This figure shows an example of a medical claim form including an initial consultation fee in an embodiment of the present invention. [Figure 31] This figure shows an example of injury / illness-related data in an embodiment of the present invention. [Figure 32] This figure shows an example of injury / illness-related data in an embodiment of the present invention. [Figure 33] This figure shows an example of injury / illness-related data in an embodiment of the present invention. [Figure 34] This figure shows an example of injury / illness-related data in an embodiment of the present invention. [Figure 35] This is a flowchart showing the medical expense decomposition analysis process in an embodiment of the present invention. [Modes for carrying out the invention]

[0017] [Device configuration] The medical expense breakdown and analysis device 100 in the embodiment of the present invention is configured to include a processing unit 10, a storage unit 12, an input unit 14, an output unit 16, and a communication unit 18, as shown in Figure 1. The medical expense breakdown and analysis device 100 may be connected to an external information processing device installed in a medical institution or a dispensing pharmacy via an information and communication network 102 such as the Internet, enabling information exchange.

[0018] Furthermore, the information and communication network 102 is not limited to the Internet, but can be any network that enables communication between the medical expense breakdown and analysis device 100 and external devices. For example, it may be a dedicated line, a public line (telephone line, mobile communication line, etc.), a wired LAN (Local Area Network), a wireless LAN, or a combination of these.

[0019] The processing unit 10 includes means for performing calculation processing such as a CPU. The processing unit 10 executes a medical expense breakdown analysis process in the medical expense breakdown analysis device 100, which analyzes medical information and appropriately allocates medical expenses, by executing a medical expense breakdown analysis program stored in the storage unit 12. The storage unit 12 includes storage means such as semiconductor memory or a memory card. The storage unit 12 is connected to the processing unit 10 in an accessible manner and stores the medical expense breakdown analysis program and information necessary for its processing. The input unit 14 includes means for inputting information. The input unit 14 includes, for example, a keyboard, touch panel, buttons, etc., for receiving input from the user. The output unit 16 includes a user interface screen (UI) for receiving input information from the user and means for outputting the results of the medical expense breakdown analysis process. The output unit 16 includes, for example, a display. The communication unit 18 is configured to include an interface for communicating information with external devices via the information communication network 102. Communication by the communication unit 18 can be wired or wireless.

[0020] The medical expense breakdown and analysis device 100 can be a stationary or portable game console, a stationary or portable personal computer (PC), a tablet computer, a smartphone, a mobile phone terminal, a PHS (Personal Handy-phone System) terminal, a personal digital assistant (PDA), or a multi-functional television receiver equipped with information processing capabilities (so-called smart TV).

[0021] [Medical Claims and Information Database] The configuration of the medical expense breakdown and analysis device 100, including the medical claim data and various information databases, will be described below. The medical claim data and various information databases are stored in the storage unit 12 of the medical expense breakdown and analysis device 100.

[0022] Figure 2 shows an example of a medical fee statement (receipt) issued when a patient receives medical services such as examinations, medication, tests, and surgery at a medical institution. A medical fee statement is a document that a medical institution uses to claim reimbursement from the insurer (for example, a health insurance association or national health insurance) when it provides insured medical services. The medical fee statement contains details of the medical services, treatments, tests, and medications the patient received, and the insurer pays the medical fee to the medical institution based on this information.

[0023] A medical fee statement includes basic information such as the statement number, medical record number, reception number, year and month the statement was issued, patient's name, gender, date of birth, insurer number, symbol / number, insurer name, name and address of the medical institution that provided treatment, telephone number, and date of consultation. In addition, a medical fee statement also includes information on the content of treatment, which shows the specific treatment or procedure, the points for the treatment (points that serve as the basis for the cost), medication information such as the type, quantity, and method of use of prescribed drugs, information on tests and diagnostic imaging performed, and information on the points for medication, tests, diagnostic imaging, etc.

[0024] Figure 3 shows an example of a prescription claim form (receipt) issued when a pharmacy dispenses medication. The prescription claim form details the dispensing fees for the medication provided to the patient. The prescription claim form includes basic information such as the claim number, receipt number, reception number, year and month the claim was issued, the patient's name, gender, date of birth, insurer number, symbol / number, insurer name, name and address of the medical institution that issued the prescription, and the doctor's name. The prescription claim form also includes information on the medical treatment details of the prescribed medication, such as the drug name, dosage form, and usage / dosage, as well as information on the quantity dispensed, drug cost, dispensing fee, points related to pharmaceutical management fees, and the insurance co-payment rate.

[0025] In this embodiment, medical procedures (medical treatment, medication, injections, treatments, surgeries, examinations / pathology, diagnostic imaging, hospitalization, etc.) for which points are assigned in relation to medical insurance claims as defined by the Ministry of Health, Labour and Welfare (Minister of Health, Labour and Welfare) are collectively referred to as "medical treatment content." Specifically, the content for which points (amounts) are assigned in the medical treatment master, pharmaceutical master, specific equipment master, dental treatment master, dispensing treatment master, and home nursing care expense master provided by the Payment Fund for medical insurance claims is referred to as "medical treatment content," and the medical treatment code, pharmaceutical code, specific equipment code, dental treatment code, dispensing treatment code, and home nursing care expense code included in each of the aforementioned masters are referred to as "medical treatment content codes."

[0026] The medical expense breakdown and analysis device 100 extracts information from these medical claims and generates various information databases that serve as the source data for the medical expense breakdown and analysis process. Figure 4 shows an example of a medical claim disease name information database. Figure 5 shows an example of a medical claim summary information database.

[0027] The medical claim disease name information database stores the following information extracted from medical claims, associating it with the insurer number, treatment date, medical claim number, medical institution code, treatment start date, disease name, disease name code, primary disease name, and suspected flag. Of these, the medical claim number is an identification number uniquely assigned to each medical claim, such as a medical fee statement or dispensing fee statement. The medical institution code is an identification number uniquely assigned to the medical institution that issued the medical claim. The disease name code is a 7-digit fund code used by the payment fund, and is a code uniquely assigned to each disease name. Disease name codes are represented in the range of 0010000 to 9999999. The primary disease name is set to 1 for disease names that are marked "(primary)" in the disease name field of the medical claim, and to 0 for disease names that are not marked "(disease name) suspected" in the disease name field of the medical claim, and to 0 for disease names that are not marked "(disease name) suspected". For example, if it says "suspected liver dysfunction," the suspicion flag is set to 1, associating it with the disease name "liver dysfunction."

[0028] The claims summary information database extracts information from these claims and stores it in association with the following: insurer number, treatment date, claim number, medical institution code, type, treatment identification code, treatment content code (medical procedure code, drug code, specific equipment code, etc.), treatment content (medical procedure, drug, specific equipment, etc.), amount used, points, and number of times. Of these, the type is information that indicates the type of claims from which data such as medical fee statements and dispensing fee statements are extracted. The treatment identification code is an identification number that indicates the content of the treatment. The treatment identification code indicates what kind of medical procedure, treatment, medication, surgery, etc. was performed. Figure 6 shows the relationship between the treatment identification code and the medical procedure. The treatment content code (medical procedure code, drug code, specific equipment code, etc.) is a 9-digit code that indicates the content of the treatment, such as a medical procedure, drug, or specific equipment. For example, the medical procedure code is represented in the range of 100000000 to 199999999. Drug codes are represented in the range of 600000000 to 699999999. Specific medical device codes are represented in the range of 700000000 to 799999999. Furthermore, usage amount, points, and frequency are information indicating medical expenses.

[0029] In this way, necessary information is extracted from medical claim forms, including medical fee statements and dispensing fee statements, to generate a database of medical claim disease names and a database of medical claim summary information, which will serve as the source data for medical expense breakdown analysis.

[0030] [Medical expense breakdown analysis processing] The medical expense breakdown and analysis process in the medical expense breakdown and analysis device 100 is described below. The medical expense breakdown and analysis process uses various master information, based on the medical claim disease name information database and the medical claim summary information database, to allocate medical expenses to disease names.

[0031] As shown in Figure 7, the master information consists of a basic medical procedure master 200, a basic disease name master 220, and a basic drug master 240. The basic medical procedure master 200, the basic disease name master 220, and the basic drug master 240 are pre-stored in the storage unit 12 of the medical expense breakdown and analysis device 100. Alternatively, the basic medical procedure master 200, the basic disease name master 220, and the basic drug master 240 may be pre-stored in an external device accessible from the medical expense breakdown and analysis device 100 via the communication unit 18.

[0032] The basic medical procedure master 200 consists of a medical procedure-to-medical procedure master 202 which defines the correspondence between medical procedures, a medical procedure master 204 which associates medical procedures with codes, and an equipment-to-medical procedure master 206 which associates medical procedures with specific equipment. The basic disease name master 220 consists of a disease name master 222 which associates disease names with codes. The basic drug master 240 consists of a symptom master 242 which defines the correspondence between symptoms and codes, a drug master 244 which defines the correspondence between drugs and codes, and a drug-to-medical procedure master 246 which defines the correspondence between drugs and medical procedures.

[0033] <Processing for allocating medical expenses for medical treatment to each disease / injury> This section explains the process of allocating medical expenses based on the medical procedures described in the medical claim form to each disease name. The following medical expense breakdown and analysis process is performed on information associated with the same insured person number and the same treatment month and year in the medical claim form disease name information database and the medical claim form summary information database.

[0034] As shown in Figure 8, the disease name master 222 is master information that stores disease name codes, disease names, and classification codes in association. The disease name code is a 7-digit fund code used by the Ministry of Health, Labour and Welfare, as described above, and is a code uniquely assigned to each disease name. The classification code is a code assigned to disease names, and is a code that groups diseases by the first 12 digits.

[0035] For example, in the example in Figure 8, seasonal allergic rhinitis, perennial allergic rhinitis, and allergic rhinitis are grouped by the classification code "100401001030". Similarly, other disease names are grouped by the first 12 digits of the classification code according to their characteristics.

[0036] As shown in Figure 9, the medical procedure master 204 is master information that stores medical procedure codes, classification codes, names, and disease name classification codes in association. The classification code is the classification code listed in the medical fee schedule. The classification code is used in association with other medical procedures and pharmaceuticals. The disease name classification code is a code used to associate with disease names. The first 12 digits of the disease name classification code are associated with the classification code in the disease name master 222.

[0037] As described above, the information regarding disease names in the disease name master 222 and the information regarding medical procedures in the medical procedure master 204 are linked via classification codes.

[0038] The medical expense breakdown and analysis device 100 sequentially reads out information about medical treatments contained in the medical claim summary information database for each medical treatment (i.e., each row in the medical claim summary information database). It compares the medical treatment content code (medical treatment code) related to the medical treatment among the read information with the medical treatment code in the medical treatment master 204, and extracts the disease name classification code corresponding to the matching medical treatment code from the medical treatment master 204. Furthermore, it compares the disease name classification code extracted from the medical treatment master 204 with the classification code in the disease name master 222, and extracts all disease name codes associated with the matching classification code.

[0039] Next, the system refers to the medical claim disease name information database and checks whether a disease name code matching the disease name code extracted from the disease name master 222 is included in the medical claim disease name information database. If a disease name code matching the disease name code extracted from the disease name master 222 is included, the information associated with that matching disease name code is read from the medical claim disease name information database and output as disease-related data, associated with the medical treatment content (medical procedure) information previously read from the medical claim summary information database. If a disease name code matching the disease name code extracted from the disease name master 222 is not included, that is, if there is no disease name in the medical claim disease name information database that is directly related to the medical procedure read from the medical claim summary information database, the medical expenses corresponding to that medical procedure will be subject to proportional allocation. Proportional allocation will be described later.

[0040] In addition, in the above process, it is also possible to use master information that directly associates medical procedure codes with disease name codes without applying disease name classification codes. In this case, disease name codes associated with medical procedure codes (medical procedure codes) read from the claims summary information database are extracted from the master information, and a comparison is performed with the claims disease name information database based on these disease name codes. Then, the information associated with the matching disease name codes is read from the claims disease name information database, associated with the medical procedure information previously read from the claims summary information database, and output as disease-related data.

[0041] Furthermore, if the medical treatment (medical procedure) concerns an initial consultation, examination, or diagnostic imaging, the system will also perform a match with the suspected flag of 1 in the claims disease name information database to associate the disease with the medical treatment (medical procedure) and output it as disease-related data. Specifically, if the medical identification code is 11 (initial consultation), 60 (examination), or 70 (diagnosis), the system will perform a match with the disease regardless of whether the suspected flag is 0 or 1 in the claims disease name information database to associate the disease with the medical treatment (medical procedure). In contrast, if the medical treatment (medical procedure) concerns a follow-up consultation, medical management, home care, general medication, general injections, procedures, surgery, anesthesia, other hospitalization-related matters, or the prescription section of a dispensing claims, the system will not perform a match with the suspected flag of 1 in the claims disease name information database, and will not associate the disease with the medical treatment (medical procedure). Instead, the system will only perform a match with the suspected flag of 0 to associate the disease with the medical treatment (medical procedure). Specifically, for medical identification codes 12 (follow-up visit), 13 (medical management), 14 (home care), 21-28 (general medication), 31-33, 39 (general injections), 40 (procedure), 50 (surgery), 54 (anesthesia), 80 (other), 90, 92, 97 (general hospitalization-related), and prescription fields on dispensing claims, matching will not be performed for illnesses with a suspected flag of 1 in the claims illness name information database, and no correspondence will be made between illnesses and medical treatment (medical procedures).

[0042] However, if the medical claim only contains suspected illnesses, it is preferable to treat all illnesses as unsuspecting illnesses.

[0043] Furthermore, the same approach to handling the above-mentioned suspicion flag will be applied to all sorting processes (including exceptions) described later.

[0044] Figure 10 shows an example of disease-related data output from the medical expense breakdown analysis device 100. The disease-related data associates the following: insurer number, year and month of treatment, claim number, medical institution code, treatment start date, disease name, disease name code, primary disease name, suspected flag, summary item {treatment content code (medical procedure code, drug code, specific equipment code, etc.), treatment content (medical procedure, drug, specific equipment, etc.)}, amount used, points, and number of times.

[0045] <Processing for allocating medical expenses for pharmaceuticals according to the name of the illness or injury> Next, I will explain the process of allocating medical expenses for pharmaceuticals according to the name of the illness or injury.

[0046] The Ministry of Health, Labour and Welfare manages pharmaceuticals using payment fund codes that represent the product names. Information linking pharmaceuticals to disease names is described in the efficacy and effects section of the drug's package insert. In this embodiment, the generic names of pharmaceuticals described in the drug's package insert are coded, and the relationship information between generic names and disease names is stored and used as symptom master 242 and drug master 244.

[0047] For example, the package insert for omeprazole tablets lists the generic name "omeprazole enteric-coated tablets." This generic name is associated with the generic name code of the drug, as shown in Figure 11(a). Furthermore, as shown in Figure 11(b), a generic name code is assigned to the drug related to omeprazole tablets. In addition, as shown in Figure 11(c), the symptoms listed in the efficacy and effects section of the package insert are associated with the generic name code.

[0048] Figure 12 shows an example of a drug master 244. The drug master 244 stores the drug code (fund code) corresponding to the drug payment fund code, the generic name code, and the drug name in association. Figure 13 shows an example of a symptom master 242. The symptom master 242 stores the generic name code, the symptom name, and the disease classification code in association.

[0049] The medical expense breakdown and analysis device 100 sequentially reads out information about medical treatments contained in the claims summary information database for each medical treatment (i.e., each row in the claims summary information database). It compares the medical treatment code (drug code) related to pharmaceuticals among the read information with the drug code (fund code) in the drug master 244, and extracts the generic name code corresponding to the matching drug code (fund code) from the drug master 244. It also compares the generic name code extracted from the drug master 244 with the generic name code in the symptom master 242, and extracts all disease name classification codes for symptoms corresponding to the matching generic name codes. Furthermore, it compares the disease name classification code extracted from the symptom master 242 with the classification code in the disease name master 222, and extracts all disease name codes associated with the matching classification code.

[0050] Next, the system refers to the claims disease name information database and checks whether a disease name code matching the disease name code extracted from the disease name master 222 is included in the claims disease name information database. If a disease name code matching the disease name code extracted from the disease name master 222 is included, the information associated with that matching disease name code is read from the claims disease name information database and output as disease-related data, associated with the drug information previously read from the claims summary information database. If a disease name code matching the disease name code extracted from the disease name master 222 is not included, that is, if there is no disease name in the claims disease name information database that is directly related to the drug read from the claims summary information database, the medical expenses corresponding to that drug will be subject to proportional allocation. Proportional allocation will be described later.

[0051] In addition, in the above process, instead of applying generic name codes, master information that directly associates drug fund codes with disease name codes may be used. In this case, disease name codes associated with the medical treatment content codes (drug codes) read from the claims summary information database can be extracted from the master information, and a comparison can be made with the claims disease name information database based on these disease name codes. Then, the information associated with the matching disease name codes can be read from the claims disease name information database and output as disease-related data, associated with the drug information previously read from the claims summary information database.

[0052] Figure 14 shows an example of disease-related data output from the medical expense breakdown analysis device 100. The disease-related data associates the following: insurer number, year and month of treatment, claim number, medical institution code, treatment start date, disease name, disease name code, primary disease name, suspected flag, summary item {treatment content code (medical procedure code, drug code, specific equipment code, etc.), treatment content (medical procedure, drug, specific equipment, etc.)}, amount used, points, and number of times.

[0053] <Exceptions to the process of allocating medical expenses for medical treatment by disease name> Next, we will explain how to handle cases where the remarks section of a medical claim includes medical expenses related to medical procedures that cannot be directly assigned to a disease name. For example, if the remarks section of a medical claim states "Mucosal Ink Dosage Surcharge," this medical expense cannot be assigned to a disease name. This is because "Mucosal Ink Dosage Surcharge," which is a technical fee for a medical procedure, cannot be directly associated with a disease name.

[0054] In such cases, a medical treatment master 202, which links disease name codes with medical treatment codes, is used to assign medical treatments (or related actions such as technical fees for medical treatments) to disease names.

[0055] Figure 15 shows an example of the treatment-to-treatment master 202. The treatment-to-treatment master 202 stores the source code, source treatment procedure, partner code, and category in association. The source code is a code uniquely assigned to treatment procedures that are not directly associated with disease names. The source treatment procedure is the name of the treatment procedure corresponding to the source code. The partner code is either a treatment content code or a classification code of the treatment procedure associated with the source code and the treatment procedure. The category is set to 0 if the partner code is a treatment content code, and to 1 if the partner code is a classification code of the treatment procedure.

[0056] The medical expense breakdown and analysis device 100 reads information about medical treatment contained in the medical claim summary information database. It compares the medical treatment content code (medical procedure code) from the read information with the medical procedure code in the medical procedure master 204, and if there is no matching medical procedure code in the medical procedure master 204, it performs the following processing using the medical treatment-to-medical treatment master 202.

[0057] The medical expense breakdown and analysis device 100 refers to the medical treatment master 202 and searches for the source code that matches the medical treatment content code (medical procedure code) among the read information. Then, it extracts the corresponding partner code from the medical treatment master 202 for the source code that matches.

[0058] Next, if the classification associated with the extracted counterpart code is 0, a comparison is made with the medical procedure code in the medical procedure master 204. If a medical procedure code matching the extracted counterpart code exists in the medical procedure master 204, the disease name classification code associated with that medical procedure code is extracted. Furthermore, the disease name classification code extracted from the medical procedure master 204 is compared with the classification code in the disease name master 222, and all disease name codes associated with the matching classification code are extracted.

[0059] On the other hand, if the category associated with the extracted partner code is 1, a comparison is made with the classification code in the medical procedure master 204. If a classification code matching the extracted partner code exists in the medical procedure master 204, the disease name classification code associated with that classification code is extracted. Furthermore, the disease name classification code extracted from the medical procedure master 204 is compared with the classification code in the disease name master 222, and all disease name codes associated with the matching classification code are extracted.

[0060] Subsequently, the system refers to the claims disease name information database and checks whether a disease name code matching the disease name code extracted from the disease name master 222 is included in the claims disease name information database. If a disease name code matching the disease name code extracted from the disease name master 222 is included, the information associated with that matching disease name code is read from the claims disease name information database and output as disease-related data, associated with the medical treatment content (medical procedure) information previously read from the claims summary information database. If a disease name code matching the disease name code extracted from the disease name master 222 is not included, that is, if there is no disease name in the claims disease name information database that is directly related to the medical procedure read from the claims summary information database, the medical expenses corresponding to that medical procedure will be subject to proportional allocation. Proportional allocation will be described later.

[0061] <Exceptions to the process of allocating medical expenses for pharmaceuticals by disease name> Next, we will explain how to handle cases where the remarks section of a medical claim includes medical expenses for medications that cannot be directly assigned to a disease name. For example, if the remarks section of a medical claim lists medications that cannot be directly associated with a disease name, such as medications administered during imaging diagnostics, these medical expenses cannot be assigned to a disease name.

[0062] In such cases, the drug is assigned to the disease name using the drug-to-medical treatment master 246, which defines the correspondence between drugs and medical treatments.

[0063] Figure 16 shows an example of the drug-to-treatment master 246. The drug-to-treatment master 246 stores associated generic name codes, symptom names, and medical procedure classification codes. The generic name code is a code uniquely assigned to each generic name of a drug. The symptom name can be, for example, the efficacy / effect name from the drug's package insert. The medical procedure classification code is a code used to associate with medical procedures and is used to link with the classification code of the medical procedure master 204.

[0064] The medical expense breakdown and analysis device 100 reads information about medical treatment (drugs) contained in the claims summary information database. It compares the medical treatment code (drug code) from the read drug information with the drug code (fund code) in the drug master 244 and extracts the generic name code corresponding to the matching drug code (fund code) from the drug master 244. Next, it compares the generic name code extracted from the drug master 244 with the generic name code in the drug-to-treatment master 246 and extracts the classification code of the medical procedure corresponding to the matching generic name code from the drug-to-treatment master 246. Then, it compares the extracted classification code of the medical procedure with the classification code in the medical procedure master 204. If there is a classification code in the medical procedure master 204 that matches the classification code of the medical procedure extracted, it extracts the medical procedure code and disease name classification code associated with that classification code. Furthermore, it compares the disease name classification code extracted from the medical procedure master 204 with the classification code in the disease name master 222 and extracts the disease name code associated with the matching classification code.

[0065] Subsequently, the system refers to the claims summary information database and extracts from the claims summary information database the medical treatment content (medical treatment) associated with the medical treatment content code (medical treatment code) that matches the medical treatment code extracted from the medical treatment master 204.

[0066] Furthermore, if medical treatment details (medical procedures) can be extracted from the claims summary information database, a check is performed to see if a disease name code matching the disease name code extracted from the disease name master 222 is included in the claims disease name information database. If a disease name code matching the disease name code extracted from the disease name master 222 is included, the information associated with that matching disease name code is read from the claims disease name information database and output as disease-related data, associated with the information on the medicine previously read from the claims summary information database. If a disease name code matching the disease name code extracted from the disease name master 222 is not included, that is, if there is no disease name in the claims disease name information database that is directly related to the medical procedure read from the claims summary information database, the medical expenses corresponding to that medicine will be subject to proportional allocation. Proportional allocation will be described later.

[0067] In addition, in the above process, instead of applying generic name codes and classification codes, master information that directly associates drug codes and medical procedure codes may be used. In this case, the medical procedure codes associated with the medical content codes (drug codes) read from the claims summary information database can be extracted from the master information, and a comparison can be made with the disease-related data based on these medical procedure codes. Then, the information directly associated with the matching medical procedure codes can be read from the disease-related data, associated with the drug information previously read from the claims summary information database, and output as disease-related data.

[0068] <Processing to allocate medical expenses related to specific medical equipment according to the name of the illness or injury> Medical claims may contain information about specific medical devices (specific health and medical materials) that cannot be categorized into disease names using the above processing. In the medical claims summary information database, such specific medical devices are represented by a medical treatment content code whose first digit starts with 7 (or by a record identifier called TO).

[0069] Figure 17 shows an example of a medical claim form that includes information about specific medical equipment. In this claim form, the item "Endoscope film fee" corresponds to the specific medical equipment.

[0070] Figure 18 shows an example of a claim diagnosis information database generated from the claim. Figure 19 shows an example of a claim summary information database generated from the claim. In the claim summary information database shown in Figure 19, "Endoscopy film fee" enclosed in a thick border is information related to specific equipment.

[0071] In the allocation process for medical expenses related to specific medical equipment, a different allocation process is applied to the medical expenses of specific medical equipment whose medical identification codes listed on the claim form belong to 40 (procedure), 50 (surgery), 54 (anesthesia), and 60 (examination), compared to the medical expenses of specific medical equipment belonging to other medical identification codes.

[0072] For specific medical devices whose medical identification codes belong to 40 (procedure), 50 (surgery), 54 (anesthesia), or 60 (examination), the device is associated with the first medical procedure in the group of medical procedures belonging to the same medical identification code. Here, a group of medical procedures refers to the group of medical procedures listed in the claim form from the time an identification code is set until the next medical identification code is set. Although medical identification codes 50 (surgery) and 54 (anesthesia) are different codes, they are treated as a single group.

[0073] In the case of the claim shown in Figure 17, the medical services from "EF-Stomach / Duodenum," which has the medical service identification code "60" assigned to it, to "Xylocaine Jelly 2% 5mL" are processed as a single group. Similarly, in the claim summary information database shown in Figure 19, groups of medical services described from the time a medical service identification code is assigned until the next medical service identification code is assigned are treated as a single group.

[0074] The medical expense breakdown and analysis device 100 reads information about medical treatment included in the claims summary information database, and processes the information as information about specific medical equipment if the first digit of the medical treatment code among the read information is "7". If the medical treatment identification code associated with the specific medical equipment is one of 40 (procedure), 50 (surgery), 54 (anesthesia), or 60 (examination), it searches for the first medical procedure in the group belonging to the same medical treatment identification code, and based on the medical treatment code associated with that medical procedure, it distributes the medical expenses related to the specific medical equipment by disease name and outputs them as disease-related data.

[0075] The process of extracting disease names associated with the medical treatment code (medical treatment code) associated with the first medical treatment in a group can be performed based on the process of allocating the medical expenses for the above medical treatments to each disease name, or based on an exception to the process of allocating the medical expenses for the medical treatments to each disease name.

[0076] In the case of the claim form in Figure 17 and the claim summary information database in Figure 19, "Endoscopy film fee," which has a medical treatment code of 700590000, corresponds to a specific piece of equipment. Therefore, "EF-Stomach / Duodenum," which is the first medical treatment belonging to the same group, is searched for, and an association is made with the disease name based on the medical treatment code (medical treatment code) 160093810 associated with that medical treatment. In this case, the process is executed in the same way as the process of allocating the medical expenses for the above medical treatment to each disease name, and information such as medical expenses related to "Endoscopy film fee" is associated with "Gastric submucosal tumor" in the claim disease name information database in Figure 18 and output as disease-related data.

[0077] Figure 20 shows an example of the output of disease-related data. In this disease-related data, information such as medical expenses related to the specific equipment "endoscopic film fee" is associated with the same disease name "gastric submucosal tumor" as "EF-stomach / duodenum," which is the first entry in the group of the same medical identification code.

[0078] As shown in Figure 21, the "endoscopic film fee," which is a specific piece of equipment, is associated with "EF-stomach / duodenum," the first medical treatment item in the same group. However, if there is no disease name associated with that medical treatment item, the medical expenses for that specific piece of equipment will be subject to proportional allocation. Proportional allocation will be explained later.

[0079] Furthermore, as mentioned above, although the medical identification codes 50 (surgery) and 54 (anesthesia) are different codes, they are treated as a single group. In other words, if a medical claim includes medical services with medical identification codes 50 (surgery) and 54 (anesthesia), and those medical services include an item for special equipment whose first digit of the medical identification code is 7, the claim will be processed in association with the first medical service belonging to the same group.

[0080] For example, as shown in Figure 22, in a medical claim that includes medical services with medical service identification codes 50 (surgery) and 54 (anesthesia), the item "Liquid Nitrogen / Stationary Liquid Oxygen Storage Tank," whose first digit of the medical service code is 7, is considered special equipment. In this case, "Liquid Nitrogen / Stationary Liquid Oxygen Storage Tank" is treated as a single group of medical services with medical service identification codes 50 (surgery) and 54 (anesthesia), and is processed in association with the first medical service (medical procedure) belonging to that group, "Gastrectomy (malignant tumor surgery)." Then, when the medical procedure "Gastrectomy (malignant tumor surgery)" is associated with the disease name "Gastric Body Cancer (Main)" through the process of allocating the medical expenses for the above medical procedures by disease name, the medical expense information for the special equipment "Liquid Nitrogen / Stationary Liquid Oxygen Storage Tank" is allocated to the disease name "Gastric Body Cancer (Main)."

[0081] As shown in Figure 23, if there is no medical procedure associated with the specified equipment "liquid nitrogen / stationary liquefied oxygen storage tank," the medical expenses related to said specified equipment will be subject to proportional allocation. Furthermore, even if there is a medical procedure related to the specified equipment "liquid nitrogen / stationary liquefied oxygen storage tank," but the disease name associated with that procedure does not exist in the medical claims disease name information database, the medical expenses related to said specified equipment will also be subject to proportional allocation. Proportional allocation will be explained later.

[0082] Furthermore, for medical expenses of specific equipment whose medical identification code is not one of the following: 40 (procedure), 50 (surgery), 54 (anesthesia), or 60 (examination), the allocation of medical expenses for that specific equipment is performed using the equipment-to-medical-activity master 206. For example, if a medical treatment with medical identification code 12 (follow-up visit), 13 (medical management), 14 (home care), 70 (imaging diagnosis), 80 (other), 90, or 92 (hospitalization fee related) includes an item for specific equipment, the allocation of medical expenses for that specific equipment is performed using the equipment-to-medical-activity master 206.

[0083] Figure 24 shows an example of the equipment-to-medical-procedure master 206. The equipment-to-medical-procedure master 206 stores the medical content code (specific equipment code), the name of the specific equipment corresponding to the medical content code (specific equipment code), the medical content code (medical procedure code) associated with the specific equipment, and the name of the medical procedure in association with each other.

[0084] The medical expense breakdown and analysis device 100 reads information about medical treatment included in the medical claim summary information database, and if the information includes an item for specific equipment where the first digit of the medical treatment content code is 7, and the medical treatment identification code is not one of 40 (procedure), 50 (surgery), 54 (anesthesia), or 60 (examination), it performs the following processing.

[0085] The system compares the medical treatment code (specific equipment code) of the retrieved specific equipment with the medical treatment code (specific equipment code) in the equipment-to-medical treatment master 206, and extracts the medical treatment code (medical procedure code) corresponding to the matching medical treatment code (specific equipment code) from the equipment-to-medical treatment master 206.

[0086] Furthermore, the medical treatment content codes (medical treatment codes) extracted from the equipment-to-medical treatment master 206 are compared with the medical treatment codes in the medical treatment master 204, and all disease name classification codes associated with the medical treatment corresponding to the matching medical treatment codes are extracted.

[0087] Then, the disease name classification codes extracted from the medical treatment master 204 are compared with the classification codes in the disease name master 222, and all disease name codes associated with matching classification codes are extracted.

[0088] Next, the system refers to the medical claim disease name information database and checks whether disease name codes matching those extracted from the disease name master 222 are included in the medical claim disease name information database. If a disease name code matching those extracted from the disease name master 222 is found, the system reads the information associated with that matching disease name code from the medical claim disease name information database and outputs it as disease-related data, associated with the medical expense information for specific equipment that was previously read from the medical claim summary information database.

[0089] For example, as shown in Figure 25, in a medical claim that includes medical treatment with medical treatment identification code 70 (imaging diagnosis), the item "mammography film (18×24)" whose first digit of the medical treatment identification code is 7 corresponds to special equipment. The medical treatment content code for "mammography film (18×24)" is "700330000", so by referring to the equipment-to-medical treatment master 206, all medical treatment content codes of medical treatments associated with the medical treatment content code "700330000" for the specific equipment are extracted. For example, medical treatment content codes including the medical treatment content code "170027010" for mammography (analog imaging) associated with medical treatment content code "700330000" are read out. Next, by referring to the medical treatment master 204, the disease name classification code of the medical treatment associated with the extracted medical treatment content code is extracted. For example, the disease name classification code "0201030102580" associated with the medical treatment content code "170027010" for mammography (analog imaging) is extracted. Then, by referring to the disease name master 222, all disease name codes that have a classification code matching the extracted disease name classification code are extracted. For example, the disease name code "8838474" for breast nodules associated with the disease name classification code "0201030102580" is extracted. Furthermore, by referring to the medical claim disease name information database, a check is performed to see if a disease name code matching the disease name code "8838474" extracted from the disease name master 222 is included in the medical claim disease name information database. For example, if the disease name master 222 contains a disease name code for a breast nodule that matches the disease name code "8838474", the information on the breast nodule associated with that matching disease name code will be linked to the medical expense information for the specific equipment "mammography film (18×24)" that was previously read from the claims summary information database, and output as disease-related data.

[0090] As shown in Figure 23, if there is no medical procedure associated with a specific piece of equipment in the medical claim form, the medical expenses related to that specific piece of equipment will be subject to proportional allocation. Similarly, if there is no medical procedure associated with a specific piece of equipment in the Equipment-to-Medical Procedure Master 206, the medical expenses related to that specific piece of equipment will be subject to proportional allocation. Furthermore, if there is a medical procedure associated with a specific piece of equipment in the Equipment-to-Medical Procedure Master 206, but that medical procedure is not recorded in the medical claim form, the medical expenses related to that specific piece of equipment will be subject to proportional allocation. In addition, if there is a medical procedure related to a specific piece of equipment, but the disease name associated with that medical procedure does not exist in the medical claim disease name information database, the medical expenses related to that specific piece of equipment will be subject to proportional allocation. Proportional allocation will be explained later.

[0091] For example, as shown in Figure 26, in a medical claim that includes medical treatment with medical treatment identification code 70 (diagnostic imaging), the item "Patient inhalation set for technetium-99m gas inhalation device," whose first digit of the medical treatment identification code is 7, is classified as special equipment. The medical treatment content code for "Patient inhalation set for technetium-99m gas inhalation device" is "730090000," so by referring to the equipment-to-medical treatment master 206, all medical treatment content codes of medical treatments associated with the medical treatment content code "730090000" are extracted. For example, medical treatment content codes including the medical treatment content code "170024710" for scintigraphy (whole body) associated with medical treatment content code "730090000" are read out. Next, by referring to the medical treatment master 204, the disease name classification codes of the medical treatments associated with the extracted medical treatment content codes are extracted. For example, the disease name classification code "02010301025801" associated with the medical treatment content code "170027010" for scintigraphy (whole body) is extracted. Then, by referring to the disease name master 222, all disease name codes that have a classification code matching the extracted disease name classification code are extracted. For example, the disease name code "2459001" for thyroiditis, associated with the disease name classification code "0201030102581", is extracted. Furthermore, by referring to the medical claim disease name information database, a check is performed to see if a disease name code matching the disease name code "2459001" extracted from the disease name master 222 is included in the medical claim disease name information database. At this time, since the disease name master 222 does not contain a disease name code for thyroiditis that matches the disease name code "2459001", the medical expenses for "Technetium 99m gas inhalation device patient inhalation set" are processed using proportional apportionment.

[0092] Furthermore, in the Equipment-to-Medical Procedure Master 206, if one specific piece of equipment is associated with multiple medical procedures, priority is given to selecting the medical procedures for which there are disease names that are associated with disease names included in the medical claims disease name information database. In other words, if there are medical procedures for which there are disease names that are associated with disease names included in the medical claims disease name information database and medical procedures for which there are no disease names that are associated with disease names included in the medical claims disease name information database, it is preferable to allocate the medical expenses related to the specific piece of equipment to the disease names that are associated with it.

[0093] <Processing to allocate initial consultation fees for each illness / injury> If the medical claim form includes a description of the initial consultation fee, the allocation of medical expenses for the initial consultation fee will be carried out as follows.

[0094] When the medical expense breakdown and analysis device 100 includes an item for the initial consultation fee in the medical claim form, it does not use master data, but instead uses the information on the start date of treatment and the number of treatment procedures in the information related to the disease name to allocate the medical expenses for the initial consultation fee.

[0095] As shown in Figure 27, if the month and year of treatment for the illness listed on the medical claim form are the same as the month and year of treatment covered by the medical claim form, the illness will be processed as an item for allocation of medical expenses for the initial consultation fee.

[0096] For example, as shown in Figure 28, if the medical claim includes an item for the first consultation, it is associated with the disease name of the consultation start date closest to the beginning of the month, within the same year as the consultation month. In this case, as shown in Figure 29, the medical expenses for the first consultation are allocated to the disease name, diabetes.

[0097] For example, as shown in Figure 30, if the medical claim includes an item for the first consultation and there are two or more first consultations, the illness names for the consultation start dates are associated with the earliest consultation start date within the same month as the consultation start date. In this case, as shown in Figure 31, the medical expenses for the first first consultation are allocated to the common cold, which is the illness name corresponding to the consultation start date closest to the beginning of the month, and the medical expenses for the second first consultation are allocated to hyperlipidemia, which is the illness name corresponding to the second consultation start date closest to the beginning of the month.

[0098] If a medical claim form indicates an initial consultation, but the month and year of treatment commencement recorded on the claim form does not correspond to the month and year of treatment covered by the claim form, the medical expenses for that initial consultation will be subject to proportional allocation. Proportional allocation will be explained later.

[0099] <Processing to allocate medical expenses for management fees according to the name of the illness or injury> If a management fee is listed on the medical claim form and this management fee is applied to the primary diagnosis, the allocation of medical expenses for the management fee will be as follows. Note that a management fee refers to a medical procedure listed on the medical claim form that is predetermined to be treated as a management fee for a specific diagnosis.

[0100] If a medical procedure described on a medical claim is determined to be a management fee, the medical expense breakdown and analysis device 100 reads information about the medical procedure corresponding to the management fee from the medical claim summary information database. The device compares the medical procedure code (medical procedure code) from the read information with the medical procedure code in the medical procedure master 204 and extracts the disease name classification code corresponding to the matching medical procedure code from the medical procedure master 204. Furthermore, the device compares the disease name classification code extracted from the medical procedure master 204 with the classification code in the disease name master 222 and extracts all disease name codes associated with the matching classification code.

[0101] Next, the system refers to the claims disease name information database and checks whether a disease name code matching the disease name code extracted from the disease name master 222 is included in the claims disease name information database. If a disease name code matching the disease name code extracted from the disease name master 222 is included, the system determines whether there is a disease name for which the primary disease name associated with that disease name code is 1. If there is a disease name for which the primary disease name is 1 (a disease name that corresponds to the primary disease name), the system reads the information associated with the disease name code of that disease name from the claims disease name information database, associates it with the information on medical procedures corresponding to management fees that was previously read from the claims summary information database, and outputs it as disease-related data. If no disease name codes match those extracted from Disease Name Master 222, or if disease name codes matching those extracted from Disease Name Master 222 exist but only disease names with a primary disease name of 0 exist (i.e., only disease names that do not correspond to a primary disease name exist), the medical expenses corresponding to the medical treatment will be subject to proportional allocation. Proportional allocation will be explained later.

[0102] <Processing for allocating medical expenses related to prescriptions and medical treatments by disease name> If a medical claim form includes a description of a medical service related to pharmaceuticals, the allocation of medical expenses for that medical service related to pharmaceuticals will be carried out as follows. Note that a medical service related to pharmaceuticals refers to a medical service described in the medical claim form that is predetermined to be processed as a medical service related to pharmaceuticals. Specifically, examples of medical services related to pharmaceuticals include prescription fees, dispensing fees and basic dispensing fees listed in the medical fee statement (receipt) when dispensing medications in-house, and dispensing fees and basic dispensing fees listed in the dispensing fee statement (receipt).

[0103] Medical expenses related to pharmaceuticals are allocated to medications listed under medical treatment identification numbers 20-28 and injections or medications with reduced drug fees listed under medical treatment identification numbers 30-39 in the dispensing fee statement (receipt) or in-hospital prescriptions.

[0104] Figure 32 shows an example of disease-related data in which medical expenses for each medical service (medical procedures, pharmaceuticals, specific equipment, etc.) are allocated to each disease name through the various processes described above. The process for allocating dispensing fees (inpatient) and basic dispensing fees (inpatient) for this example of disease-related data will be explained below.

[0105] Dispensing fees (inpatient) and basic dispensing fees (inpatient) are medical expenses for medical services related to pharmaceuticals that cannot be directly linked to a specific disease name. Medical expenses for such services, which involve pharmaceuticals but cannot be directly linked to a specific disease name, are distributed equally among the disease names associated with the pharmaceuticals. The medical service code (pharmaceutical code) for pharmaceutical-related medical services is represented within the range of 600000000 to 699999999.

[0106] For example, if the dispensing fee (inpatient) is 42 points and the basic dispensing fee (inpatient) is 14 points, the total points for these are 56 points. Also, in the example of disease-related data shown in Figure 32, pharmaceuticals and their medical expenses are associated with two disease names: hypertension and dyslipidemia (shown by thick lines in Figure 32). Therefore, the total points for the dispensing fee (inpatient) and the basic dispensing fee (inpatient) are distributed equally among these two disease names. That is, the total points of 56 points for the dispensing fee (inpatient) and the basic dispensing fee (inpatient) are distributed equally among the two disease names, 28 points each.

[0107] As a result, as shown in Figure 33, medical expenses related to dispensing fees (inpatient) and basic dispensing fees (inpatient) are linked to two disease names, hypertension and dyslipidemia, in the drug-related items (shown by thick lines in Figure 33).

[0108] Alternatively, the points for the dispensing fee (inpatient) and the basic dispensing fee (inpatient) may be equally allocated to these two disease names. In this case, the 42 points for the dispensing fee (inpatient) would be equally allocated to the two disease names at a rate of 21 points each. In addition, the 14 points for the basic dispensing fee (inpatient) would be equally allocated to the two disease names at a rate of 7 points each.

[0109] <Proportional apportionment> This section explains how to allocate medical expenses for treatments that could not be categorized under a disease name in any of the above processes and were therefore subject to proportional allocation.

[0110] Medical expenses for treatments subject to proportional allocation are distributed to disease names associated with any of the above treatments. First, the medical expenses for disease names associated with any of the above treatments are totaled, and the ratio of points for each disease name is calculated. Next, the total medical expenses for treatments subject to proportional allocation are totaled. Finally, the total medical expenses for treatments subject to proportional allocation are distributed to each disease name according to the calculated ratio of points for each disease name.

[0111] This section explains the process of allocating medical expenses related to the special basic inpatient fee for general wards, the additional fee for length of stay in general wards, and the additional fee for Grade 3 regional areas, using the example of illness-related data shown in Figure 33.

[0112] The basic general ward special inpatient fee, the general ward inpatient period surcharge, and the Class 3 area surcharge are medical expenses for medical services (medical procedures) that cannot be directly linked to a specific disease name. Therefore, these medical expenses are allocated proportionally to disease names to which some medical service is already associated.

[0113] For example, if the total of the basic general ward special inpatient fee and the general ward inpatient period surcharge is 1,750 points, and the Class 3 regional surcharge is 24 points, the total points for these combined would be 1,774 points.

[0114] Furthermore, in the example of disease-related data shown in Figure 33, medical expenses for some form of treatment are already associated with three disease names: allergic rhinitis, hypertension other than obesity, sleep apnea syndrome, and dyslipidemia. First, we calculate the total points for medical expenses for these three disease names. Hypertension is allocated a total of 348 points (=40+280+56 / 2). Sleep apnea syndrome is allocated a total of 3,440 points (=3,300+140). Dyslipidemia is allocated a total of 98 points (=70+56 / 2). The total points for medical expenses for the three disease names is 3,886 points.

[0115] Next, we calculate the point ratio for medical expenses for the three disease names. For hypertension, the total points of 348 are divided by the total points of 3,886, resulting in 9%. For sleep apnea syndrome, the total points of 3,440 are divided by the total points of 3,886, resulting in 88%. For dyslipidemia, the total points of 98 are divided by the total points of 3,886, resulting in 3%.

[0116] Then, the total medical expenses for the treatments subject to proportional allocation are distributed to each disease according to the calculated point ratio for each disease. For hypertension, 160 points are allocated by multiplying the total medical expenses for the treatments subject to proportional allocation of 1,774 points by a point ratio of 9%. For sleep apnea syndrome, 1,561 points are allocated by multiplying the total medical expenses for the treatments subject to proportional allocation of 1,774 points by a point ratio of 88%. For dyslipidemia, 53 points are allocated by multiplying the total medical expenses for the treatments subject to proportional allocation of 1,774 points by a point ratio of 3%.

[0117] As a result, as shown in Figure 34, the medical expenses related to the special basic inpatient fee for general wards, the additional fee for the length of stay in general wards, and the additional fee for a Class 3 area can be allocated proportionally to each disease name: hypertension, sleep apnea syndrome, and dyslipidemia (shown by the thick lines in Figure 34).

[0118] <Procedure for analyzing medical expenses> Referring to the flowchart in Figure 35, the procedure for the medical expense breakdown analysis process in the medical expense breakdown analysis device 100 will be explained.

[0119] In step S10, the medical expenses for medical treatment are allocated according to the name of the illness or injury. Through the processing in this step, the medical expense breakdown and analysis device 100 functions as a means for allocating medical treatment. The medical expense breakdown and analysis device 100 processes the medical expenses based on the medical treatment described in the medical claim form to each name of the illness or injury.

[0120] In step S12, the medical expenses for pharmaceuticals are allocated according to the name of the illness or injury. Through the processing in this step, the medical expense breakdown and analysis device 100 functions as a pharmaceutical allocation means. The medical expense breakdown and analysis device 100 processes the medical expenses for pharmaceuticals listed on the claim form to be allocated according to the name of the illness or injury.

[0121] In step S14, an exception is made to the process of allocating medical expenses for medical procedures to each disease name. Through the processing in this step, the medical expense breakdown and analysis device 100 functions as a means of exception to the allocation of medical procedures. The medical expense breakdown and analysis device 100 indirectly allocates medical expenses for medical procedures to each disease name by associating medical procedures that cannot be directly allocated to each disease name with other medical procedures.

[0122] In step S16, an exception is made to the process of allocating the medical expenses of pharmaceuticals to each disease name. Through the processing in this step, the medical expense breakdown and analysis device 100 functions as a pharmaceutical allocation exception means. The medical expense breakdown and analysis device 100 indirectly allocates the medical expenses of pharmaceuticals to each disease name by associating pharmaceuticals that cannot be directly allocated to each disease name with medical treatment.

[0123] In step S18, the medical expenses are allocated to each disease name. Through the processing in this step, the medical expense breakdown and analysis device 100 functions as an individual allocation means. The medical expense breakdown and analysis device 100 processes medical expenses for medical services that cannot be directly allocated to disease names, such as medical expenses related to specific equipment, initial consultation fees, and management fees, and allocates them to disease names.

[0124] In step S20, the medical expenses for medical services related to prescriptions are allocated according to the name of the illness or injury. Through the processing in this step, the medical expense breakdown and analysis device 100 functions as a pharmaceutical-related allocation means. The medical expense breakdown and analysis device 100 processes the medical expenses for medical services related to pharmaceuticals to be allocated according to the name of the illness or injury.

[0125] In step S22, the medical expenses for the treatment content are allocated proportionally to the disease name. Through the processing in this step, the medical expense decomposition and analysis device 100 functions as a proportional allocation means. The medical expense decomposition and analysis device 100 then allocates the medical expenses for the treatment content that could not be allocated to the disease name in the above processing proportionally to each disease name.

[0126] As described above, this embodiment makes it possible to appropriately allocate medical expenses, which were not properly allocated in the conventional technology, to each illness or injury.

[0127] [Structure of the invention] [Configuration 1] A medical expense breakdown and analysis device, A medical claim disease name information database that associates the disease name listed on the medical claim with the disease name code of that disease, A claims summary information database that associates the medical treatment details described on the claims with the medical treatment code indicating said medical treatment and the medical expenses for said medical treatment, Master information relating the aforementioned disease name code and the aforementioned medical treatment content code, Accessible, The medical treatment content code indicating the medical treatment content is read from the aforementioned medical claim summary information database, By referring to the aforementioned master information, read the disease name code associated with the medical treatment content code that was read out, From among the disease name codes included in the aforementioned medical claim disease name information database, select the disease name code associated with the read disease name code, The process involves associating the disease name of the disease name code selected in the aforementioned medical claim disease name information database with the medical expenses associated with the medical treatment content code read from the aforementioned medical claim summary information database and outputting them together. A medical expense decomposition and analysis device characterized by, when there is a medical treatment that does not correspond to any of the disease name codes included in the medical claim disease name information database by referring to the master information, allocating the medical expenses for the unrelated medical treatment to the disease names that are associated with medical expenses at a predetermined ratio. [Configuration 2] The medical expense breakdown and analysis device described in Configuration 1, The medical expense decomposition and analysis device is characterized in that the predetermined ratio is the ratio of medical expenses for each disease name, which is obtained by allocating the medical expenses for treatment content associated with any disease name to each disease name out of the total medical expenses in the medical claim summary information database. [Configuration 3] A medical expense breakdown and analysis device as described in configuration 1 or 2, A medical expense decomposition and analysis device characterized by associating the medical expenses for a medical treatment, including suspected disease names, when the medical treatment content included in the aforementioned medical claim summary information database is a predetermined medical treatment. [Structure 4] The medical expense breakdown and analysis device described in configuration 3, A medical expense breakdown and analysis device characterized in that the aforementioned prescribed medical treatment content relates to either an initial consultation, an examination, or a diagnostic imaging test. [Composition 5] A medical expense breakdown and analysis device as described in configuration 1 or 2, A medical expense decomposition and analysis device characterized by associating the medical expenses for a prescribed medical treatment with the medical expenses for that prescribed medical treatment, based on the date the treatment for the disease began and the number of times the initial consultation fee was charged. [Composition 6] The medical expense breakdown and analysis device described in configuration 5, A medical expense breakdown and analysis device characterized in that the aforementioned prescribed medical treatment content is related to the initial consultation. [Composition 7] A medical expense breakdown and analysis device as described in configuration 1 or 2, A medical expense decomposition and analysis device characterized by associating the medical expenses of a medical treatment content, limited to the primary disease name only, when the medical treatment content included in the aforementioned medical claim summary information database is a predetermined medical treatment content. [Structure 8] The medical expense breakdown and analysis device described in Configuration 7, A medical expense breakdown and analysis device characterized in that the aforementioned prescribed medical treatment content is related to medical management. [Composition 9] A medical expense breakdown and analysis device according to any one of items 1 to 8, A medical expense decomposition and analysis device characterized by changing the order of association processing between medical expenses and disease names for each medical treatment identification in the medical treatment content included in the aforementioned medical claim summary information database. [Configuration 10] This is a medical expense breakdown analysis program, A medical claim disease name information database that associates the disease name listed on the medical claim with the disease name code of that disease, A claims summary information database that associates the medical treatment details described on the claims with the medical treatment code indicating said medical treatment and the medical expenses for said medical treatment, Master information relating the aforementioned disease name code and the aforementioned medical treatment content code, On a computer that has access to it, The medical treatment content code indicating the medical treatment content is read from the aforementioned medical claim summary information database, By referring to the aforementioned master information, read the disease name code associated with the medical treatment content code that was read out, From among the disease name codes included in the aforementioned medical claim disease name information database, select the disease name code associated with the read disease name code, The process is executed to output the disease name of the disease name code selected in the aforementioned medical claim disease name information database and the medical expenses associated with the medical treatment content code read from the aforementioned medical claim summary information database, in association with each other. A medical expense decomposition analysis program characterized by, when there is a medical treatment that does not relate to any of the disease name codes included in the medical claim disease name information database by referring to the master information, executing a process to allocate the medical expenses of the unrelated medical treatment to the disease names that are associated with medical expenses at a predetermined ratio. [Composition 11] A method for analyzing the breakdown of medical expenses, A medical claim disease name information database that associates the disease name listed on the medical claim with the disease name code of that disease, A claims summary information database that associates the medical treatment details described on the claims with the medical treatment code indicating said medical treatment and the medical expenses for said medical treatment, Master information relating the aforementioned disease name code and the aforementioned medical treatment content code, On a computer that has access to it, The medical treatment content code indicating the medical treatment content is read from the aforementioned medical claim summary information database, By referring to the aforementioned master information, read the disease name code associated with the medical treatment content code that was read out, From among the disease name codes included in the aforementioned medical claim disease name information database, select the disease name code associated with the read disease name code, The process is executed to output the disease name of the disease name code selected in the aforementioned medical claim disease name information database and the medical expenses associated with the medical treatment content code read from the aforementioned medical claim summary information database, in association with each other. A medical expense decomposition analysis method characterized by, when there is a medical treatment that does not relate to any of the disease name codes included in the medical claim disease name information database by referring to the master information, executing a process to allocate the medical expenses of the unrelated medical treatment to the disease names that are associated with medical expenses at a predetermined ratio. [Explanation of Symbols]

[0128] 10 Processing unit, 12 Storage unit, 14 Input unit, 16 Output unit, 18 Communication unit, 100 Medical expense breakdown and analysis device, 102 Information and communication network, 200 Basic medical procedure master, 202 Medical treatment-to-medical treatment master, 204 Medical procedure master, 206 Equipment-to-medical procedure master, 220 Basic disease name master, 222 Disease name master, 240 Basic drug master, 242 Symptom master, 244 Drug master, 246 Drug-to-medical treatment master.

Claims

1. A medical expense breakdown and analysis device, A medical claim disease name information database that associates the disease name listed on the medical claim with the disease name code of that disease, A claims summary information database that associates the medical treatment details described on the claims with the medical treatment code indicating said medical treatment and the medical expenses for said medical treatment, Master information relating the aforementioned disease name code and the aforementioned medical treatment content code, Accessible, The medical treatment content code indicating the medical treatment content is read from the aforementioned medical claim summary information database, By referring to the aforementioned master information, read the disease name code associated with the medical treatment content code that was read out, From among the disease name codes included in the aforementioned medical claim disease name information database, select the disease name code associated with the read disease name code, The process involves associating the disease name of the disease name code selected in the aforementioned medical claim disease name information database with the medical expenses associated with the medical treatment content code read from the aforementioned medical claim summary information database and outputting them together. A medical expense decomposition and analysis device characterized by, when there is a medical treatment that does not correspond to any of the disease name codes included in the medical claim disease name information database by referring to the master information, allocating the medical expenses for the unrelated medical treatment to the disease names that are associated with medical expenses at a predetermined ratio.

2. A medical expense breakdown and analysis device according to claim 1, The medical expense decomposition and analysis device is characterized in that the predetermined ratio is the ratio of medical expenses for each disease name, which is obtained by allocating the medical expenses for treatment content associated with any disease name to each disease name out of the total medical expenses in the medical claim summary information database.

3. A medical expense breakdown and analysis device according to claim 1 or 2, A medical expense decomposition and analysis device characterized by associating the medical expenses for a medical treatment, including suspected disease names, when the medical treatment content included in the aforementioned medical claim summary information database is a predetermined medical treatment.

4. A medical expense breakdown and analysis device according to claim 3, A medical expense breakdown and analysis device characterized in that the aforementioned prescribed medical treatment content relates to either an initial consultation, an examination, or a diagnostic imaging test.

5. A medical expense breakdown and analysis device according to claim 1 or 2, A medical expense decomposition and analysis device characterized by associating the medical expenses for a prescribed medical treatment with the medical expenses for that prescribed medical treatment, based on the date the treatment for the disease began and the number of times the initial consultation fee was charged.

6. A medical expense breakdown and analysis device according to claim 5, A medical expense breakdown and analysis device characterized in that the aforementioned prescribed medical treatment content is related to the initial consultation.

7. A medical expense breakdown and analysis device according to claim 1 or 2, A medical expense decomposition and analysis device characterized by associating the medical expenses of a medical treatment content, limited to the primary disease name only, when the medical treatment content included in the aforementioned medical claim summary information database is a predetermined medical treatment content.

8. A medical expense breakdown and analysis device according to claim 7, A medical expense breakdown and analysis device characterized in that the aforementioned prescribed medical treatment content is related to medical management.

9. A medical expense breakdown and analysis device according to claim 1, A medical expense decomposition and analysis device characterized by changing the order of association processing between medical expenses and disease names for each medical treatment identification in the medical treatment content included in the aforementioned medical claim summary information database.

10. This is a medical expense breakdown analysis program, A medical claim disease name information database that associates the disease name listed on the medical claim with the disease name code of that disease, A claims summary information database that associates the medical treatment details described on the claims with the medical treatment code indicating said medical treatment and the medical expenses for said medical treatment, Master information relating the aforementioned disease name code and the aforementioned medical treatment content code, On a computer that has access to it, The medical treatment content code indicating the medical treatment content is read from the aforementioned medical claim summary information database, By referring to the aforementioned master information, read the disease name code associated with the medical treatment content code that was read out, From among the disease name codes included in the aforementioned medical claim disease name information database, select the disease name code associated with the read disease name code, The process is executed to output the disease name of the disease name code selected in the aforementioned medical claim disease name information database and the medical expenses associated with the medical treatment content code read from the aforementioned medical claim summary information database, in association with each other. A medical expense decomposition analysis program characterized by, when there is a medical treatment that does not relate to any of the disease name codes included in the medical claim disease name information database by referring to the master information, executing a process to allocate the medical expenses of the unrelated medical treatment to the disease names that are associated with medical expenses at a predetermined ratio.

11. A method for analyzing the breakdown of medical expenses, A medical claim disease name information database that associates the disease name listed on the medical claim with the disease name code of that disease, A claims summary information database that associates the medical treatment details described on the claims with the medical treatment code indicating said medical treatment and the medical expenses for said medical treatment, Master information relating the aforementioned disease name code and the aforementioned medical treatment content code, On a computer that has access to it, The medical treatment content code indicating the medical treatment content is read from the aforementioned medical claim summary information database, By referring to the aforementioned master information, read the disease name code associated with the medical treatment content code that was read out, From among the disease name codes included in the aforementioned medical claim disease name information database, select the disease name code associated with the read disease name code, The process is executed to output the disease name of the disease name code selected in the aforementioned medical claim disease name information database and the medical expenses associated with the medical treatment content code read from the aforementioned medical claim summary information database, in association with each other. A medical expense decomposition analysis method characterized by, when there is a medical treatment that does not relate to any of the disease name codes included in the medical claim disease name information database by referring to the master information, executing a process to allocate the medical expenses of the unrelated medical treatment to the disease names that are associated with medical expenses at a predetermined ratio.

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