Rule checking system and rule checking method for recognizing medical insurance reimbursement violations

Abstract

The invention discloses a rule checking system for recognizing medical insurance reimbursement violations. The rule checking system comprises a rule defining unit, a server, a type-in unit, a rule checking unit and a checking conclusion generating unit, wherein system maintenance personnel type in rules capable of recognizing the medical insurance reimbursement violations according to experience and store rule data lists and threshold values of each rule datum into a database to be used as the rule checking basis; in the rule checking process, the rule checking unit sequentially calculates a deviation value between each datum in a medical insurance settlement list and the corresponding threshold; the checking conclusion generating unit judges whether the insurance reimbursement behavior belongs to a dishonoring behavior or a suspicious behavior or a normal behavior according to the deviation value of each datum, so that the validity or the violation of the medical insurance reimbursement behavior is automatically judged.

Description

technical field [0001] The invention relates to an automatic verification system and method for medical insurance settlement documents, in particular to a rule verification system and a verification method for identifying violations 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 ...

AI Technical Summary

Problems solved by technology

In the existing technology, the review and verification of the medical insurance settlement document data are all manual review or random inspection, and it is easy to miss the illegal reimbursement document data, resulting in the loss of the medical insurance fund

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