The embodiment of the invention discloses a detection method and
system of health insurance compensation fraud and abuse. The method includes: receiving a claim application submitted by
user equipment; acquiring data, which are required for a claim, according to the claim application; according to the data required for the claim, judging whether a pre-established model
scoring engine and rule
scoring engine are called; If yes, calling the model
scoring engine on the basis of the data, which are required for the claim, to generate a model
score and a risk prompting factor, and calling the rulescoring engine to generate rule triggering results and rule risk scores; generating a
risk evaluation report according to the generated model
score, risk prompting factor, rule triggering results andrule risk scores; and according to the
risk evaluation report, obtaining a conclusion of whether the claim is finally settled, and storing claim data of the obtained claim conclusion into a historicalclaim
database. According to the embodiment of the invention, detection on health insurance compensation fraud and abuse can be realized, and accuracy and efficiency of detection are greatly improved.