Suspicious behavior audit system and method in medical insurance reimbursement process

Abstract

The invention discloses a suspicious behavior audit system in the medical insurance reimbursement process. The suspicious behavior audit system comprises a consumption information base, a retrieval unit, an expense screening unit, an analysis execution unit and a human-computer interaction unit. The retrieval unit can automatically obtain reimbursement bills to be audited from the consumption information base; multiple items of data in prescription detail information are classified through the expense screening unit; treatment registration information, expense settlement information and classified prescription detail information are displayed in the human-computer interaction unit so that audit staff can visually audit suspicious objects; meanwhile, parameters and threshold values corresponding to all the data in the prescription detail information are input into the analysis execution unit so that the analysis execution unit can conduct automatic audit on all the data in the prescription detail information; as a result, batch processing of multiple items of data is achieved, and manual audit time is greatly shortened; accordingly, by the aid of the audit system, medical insurance reimbursement bills can be audited efficiently, quickly and accurately.

Description

technical field [0001] The invention relates to an audit system and an audit method for medical insurance reimbursement documents, in particular to an audit system and an audit method for suspicious behavior in the process of medical insurance reimbursement. Background technique [0002] In order to maintain the integrity of the basic medical insurance fund and protect the insured to fully enjoy the basic medical insurance benefits, the medical management department has made clear responsibilities for violations of the basic medical insurance regulations by medical institutions, doctors, and insured persons. , in order to prevent the responsible person from defrauding the medical insurance fund, for example: in the medical insurance settlement documents, the medicines prescribed belong to the contraindicated drugs of the insured person, or are not used to treat the diseases suffered by the insured person; The department has handled multiple admissions in a row and so on. In...

AI Technical Summary

Problems solved by technology

In the existing technology, the review and verification of medical insurance reimbursement documents are manually reviewed, that is, the review personnel check the reimbursement documents one by one, the review speed and review quality are low, and it is easy to miss illegal reimbursement document data, resulting in a large number of Suspicious behaviors such as fraud, abuse, waste, etc., resulting in losses of medical insurance funds

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