Medical insurance intelligent auditing method and system

Abstract

The invention discloses a medical insurance intelligent auditing method and system. The method comprises the following steps: making a strategy that a decomposition hospitalization rule, a low-standard hospitalization rule, a key drug monitoring rule, an antibacterial drug rule and a high-cost medical institution rule correspond to an abuse type, a repeated charging rule and a gender and age limiting rule correspond to a fraud type, and an excessive drug taking rule corresponds to a waste type; acquiring medical insurance reimbursement detail data, medical insurance reimbursement data, insuredperson information data and hospital information data of the insured person; screening the medical insurance reimbursement detail data, the medical insurance reimbursement data, the insured person information data and the hospital information data; if the screened data conforms to the decomposition hospitalization rule, the low-standard hospitalization rule, the key drug monitoring rule, the antibacterial drug rule or the high-cost medical institution rule, outputting an abuse type result; outputting a fraud type result if the screened data accords with the repeated charging rule and the gender and age limiting rule; and outputting a waste type result if the screened data conforms to the excessive drug taking rule.

Description

technical field [0001] The present invention relates to the technical field of medical insurance auditing, in particular to a medical insurance intelligent auditing method and system. Background technique [0002] With the development of medical technology and the increasing demand for health of the insured, the medical expenses continue to rise, and the pressure on social medical insurance funds is also increasing. Increased the dual responsibilities of medical insurance supply and cost control. [0003] Whether it is government medical insurance or commercial medical insurance, there are frauds, abuses, and wastes. In the past, social security audits and commercial insurance surveys were mainly based on manual spot checks and document review, which was time-consuming and labor-intensive. Due to the limited number of supervisors, they can only focus on cases with high fees and high usage, and cannot detect the risks of fraud, abuse, and waste in all cases. [0004] There...

AI Technical Summary

Problems solved by technology

[0005] The present invention aims at the time-consuming and labor-intensive manual review in the prior art, and the low positive rate and low review efficiency, while the traditional intelligent review raises too many problem documents, which also adds a heavy burden to the medical insurance department and Insufficient, provide a medical insurance intelligent audit method and system

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