CN104133810A - System and method for verifying medical insurance reimbursement qualification - Google Patents
System and method for verifying medical insurance reimbursement qualification Download PDFInfo
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- CN104133810A CN104133810A CN201410389301.8A CN201410389301A CN104133810A CN 104133810 A CN104133810 A CN 104133810A CN 201410389301 A CN201410389301 A CN 201410389301A CN 104133810 A CN104133810 A CN 104133810A
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Abstract
The invention discloses a system for verifying medical insurance reimbursement qualification. The system comprises a type-in unit, a server, a verification unit and a verification result output unit, wherein the verification unit compares reimbursement document data provided by the type-in unit with the responsible qualification data provided by a server, verifies the information of a medical institution, a doctor and the insured one by one, and then judges whether the document data get out of line or not. According to the qualification verification system, automatic verification is achieved based on the information technology (IT), the traditional manual auditing and spot checking verification method is replaced, the accuracy and effectiveness of verification are improved, and loss of medical benefit funds is effectively avoided.
Description
Technical field
The present invention relates to medical insurance person liable qualification check system and method, relate in particular to a kind of medical insurance reimbursement qualification check system and medical insurance reimbursement qualification method of calibration.
Background technology
In order to safeguard the integrality of the funds of basic medical insurance, protection insurant enjoys basic medical insurance treatment to the full, medical control department is to medical institutions, doctor, the persons liable such as insured people violate the behavior of basic medical insurance regulation and have made clear and definite responsibility regulation, in case person liable gains Medical Benefits Fund by cheating, such as: list the expense within the scope of the payment for medical care of non-insured object or non-basic medical insurance payment in the funds of basic medical insurance and pay scope, or exceed fixed point service range, contract without authorization and be in hospital, hospital bed set up at a patient's home, outpatient service special disease medical profession, and forgery medical document etc., cause damage to national Medical Benefits Fund.In prior art, the audit of medical insurance reimbursement document data, verification etc. are to the mode of manual examination and verification or sampling observation, are easy to omit reimbursement document data in violation of rules and regulations, cause Medical Benefits Fund to incur loss.
Summary of the invention
The technical problem to be solved in the present invention is, for the deficiencies in the prior art, provides a kind of and can judge in time, exactly reimbursement document data medical insurance reimbursement qualification check system and medical insurance reimbursement qualification method of calibration effectively or in violation of rules and regulations.
For solving the problems of the technologies described above, the present invention adopts following technical scheme.
A medical insurance reimbursement qualification check system, it includes: a typing unit, it is for typing reimbursement document data, and described reimbursement document data comprise information for hospital, information about doctor and insured people's information; One server, it is for providing person liable's qualification data, and described person liable's qualification data comprise hospital's membership information, doctor's membership information and insured people's membership information; One verification unit, it is for obtaining reimbursement document data and obtaining person liable's qualification data, by information for hospital and the contrast of hospital membership information, information about doctor is contrasted with the contrast of doctor's membership information and by insured people's information and insured people's membership information, export afterwards comparing result again; One check results output unit, it is according to this comparing result judgement, if reimbursement document data are effective for reimbursement document data and person liable's qualification data consistent, if the inconsistent reimbursement document of any one data in reimbursement document data and person liable's qualification data in violation of rules and regulations.
A medical insurance reimbursement qualification method of calibration, the method comprises the steps: step S10, typing reimbursement document data, described reimbursement document data comprise information for hospital, information about doctor and insured people's information; Step S11, typing unit by reimbursement document data transmission to verification unit; Step S12, person liable's qualification data of storage in verification unit invoking server, described person liable's qualification data comprise hospital's membership information, doctor's membership information and insured people's membership information; Step S13, verification unit is by information for hospital and hospital's membership information contrast, if two kinds of information unanimously perform step S14, if two kinds of inconsistent S17 that perform step of information; Step S14, verification unit is by information about doctor and the contrast of doctor's membership information, if two kinds of information unanimously perform step S15, if two kinds of inconsistent S17 that perform step of information; Step S15, verification unit is by insured people's information and the contrast of insured people's membership information, if two kinds of information unanimously perform step S16, if two kinds of inconsistent S17 that perform step of information; Step S16, check results output unit generates the effective conclusion of reimbursement document data; Step S17, check results output unit generates reimbursement document data conclusion in violation of rules and regulations.
Preferably, described verification unit is by person liable's qualification data of Webservice interface or the storage of DB interface interchange server memory.
Medical insurance reimbursement qualification check system disclosed by the invention and medical insurance reimbursement qualification method of calibration, its beneficial effect is compared to existing technologies, person liable's qualification data that the reimbursement document geodata and services device that verification unit provides typing unit provides contrast, to medical institutions, doctor and insured people's information are carried out verification one by one, and then judge whether in violation of rules and regulations reimbursement document data, this qualification check system is realized automatic Verification based on IT technology, traditional manual examination and verification have been substituted, the verification mode of sampling observation, accuracy and the actual effect of checking procedure have been improved, effectively avoided Medical Benefits Fund to incur loss.
Accompanying drawing explanation
Fig. 1 is the composition frame chart of medical insurance reimbursement qualification check system of the present invention.
Fig. 2 is the process flow diagram of medical insurance reimbursement qualification method of calibration of the present invention.
Embodiment
Below in conjunction with drawings and Examples, the present invention is described in more detail.
The invention discloses a kind of medical insurance reimbursement qualification check system, as shown in Figure 1, it includes a typing unit 10, a server 11, a verification unit 12 and the check results output unit 13 being generated by computer program, wherein:
Typing unit 10 is for typing reimbursement document data, so that 12 pairs of these reimbursement document data of verification unit are carried out verification audit, described reimbursement document data comprise information for hospital, information about doctor and insured people's information;
Server 11 is for providing person liable's qualification data, described person liable's qualification data comprise hospital's membership information, doctor's membership information and insured people's membership information, these person liable's qualification data are data that maintainer collects in advance, and within being stored in server, as the contrast foundation of qualification checking procedure;
Verification unit 12 is for obtaining reimbursement document data and obtaining person liable's qualification data, by information for hospital and the contrast of hospital membership information, information about doctor is contrasted with the contrast of doctor's membership information and by insured people's information and insured people's membership information, export afterwards comparing result again;
Check results output unit 13 is according to this comparing result judgement, if reimbursement document data are effective for reimbursement document data and person liable's qualification data consistent, if the inconsistent reimbursement document of any one data in reimbursement document data and person liable's qualification data in violation of rules and regulations.
Reimbursement document data are through after verification, and the effective or violation conclusion of check results output unit 13 outputs, contributes to the unlawful practices such as swindle in medical insurance management system identification medical insurance process of consumption, abuse, waste.
Based on above-mentioned medical insurance reimbursement qualification check system, the present invention also discloses a kind of medical insurance reimbursement qualification method of calibration, and shown in Fig. 1 and Fig. 2, the method comprises the steps:
Step S10, to typing unit typing reimbursement document data, described reimbursement document data comprise information for hospital, information about doctor and insured people's information;
Step S11, typing unit by reimbursement document data transmission to verification unit 12, so that 12 pairs of these reimbursement document data of verification unit are carried out verification audit;
Step S12, verification unit 12 is by person liable's qualification data of Webservice interface or the 11 interior storages of DB interface interchange server, described person liable's qualification data comprise hospital's membership information, doctor's membership information and insured people's membership information, and these person liable's qualification data are as the contrast foundation of qualification checking procedure;
Step S13, verification unit 12, by information for hospital and hospital's membership information contrast, its role is to, by information, contrast and judge whether this hospital is effective, legal medical institutions, in comparison process, if two kinds of information unanimously perform step S14, if two kinds of inconsistent S17 that perform step of information;
Step S14, verification unit 12 is by information about doctor and the contrast of doctor's membership information, its role is to, doctor's qualification is carried out to verification, thereby whether the qualification of learning doctor is effective, whether there is prescription power, in comparison process, if two kinds of information unanimously perform step S15, if two kinds of inconsistent S17 that perform step of information;
Step S15, verification unit 12 is by insured people's information and the contrast of insured people's membership information, its role is to, whether the insured people's of verification medical treatment qualification is effective, can enjoy medical insurance reimbursement treatment etc., in comparison process, if two kinds of information unanimously perform step S16, if two kinds of inconsistent S17 that perform step of information;
Step S16, check results output unit 13 generates the effective conclusion of reimbursement document data;
Step S17, check results output unit 13 generates reimbursement document data conclusion in violation of rules and regulations.
In medical insurance reimbursement qualification check system disclosed by the invention and medical insurance reimbursement qualification method of calibration, person liable's qualification data that the reimbursement document geodata and services device that verification unit 12 provides typing unit 10 provides contrast, medical institutions, doctor and insured people's information are carried out to verification one by one, and then in violation of rules and regulations whether judgement pin bills data, this qualification check system is realized automatic Verification based on IT technology, traditional manual examination and verification, the verification mode of sampling observation have been substituted, improve accuracy and the actual effect of checking procedure, effectively avoided Medical Benefits Fund to incur loss.
The above is preferred embodiment of the present invention, is not limited to the present invention, all modifications of making in technical scope of the present invention, is equal to and replaces or improvement etc., all should be included in the scope that the present invention protects.
Claims (3)
1. a qualification check system is submitted an expense account in medical insurance, it is characterized in that including:
One typing unit, it is for typing reimbursement document data, and described reimbursement document data comprise information for hospital, information about doctor and insured people's information;
One server, it is for providing person liable's qualification data, and described person liable's qualification data comprise hospital's membership information, doctor's membership information and insured people's membership information;
One verification unit, it is for obtaining reimbursement document data and obtaining person liable's qualification data, by information for hospital and the contrast of hospital membership information, information about doctor is contrasted with the contrast of doctor's membership information and by insured people's information and insured people's membership information, export afterwards comparing result again;
One check results output unit, it is according to this comparing result judgement, if reimbursement document data are effective for reimbursement document data and person liable's qualification data consistent, if the inconsistent reimbursement document of any one data in reimbursement document data and person liable's qualification data in violation of rules and regulations.
2. a medical insurance reimbursement qualification method of calibration, is characterized in that, the method comprises the steps:
Step S10, typing reimbursement document data, described reimbursement document data comprise information for hospital, information about doctor and insured people's information;
Step S11, by reimbursement document data transmission to verification unit;
Step S12, person liable's qualification data of storage in verification unit invoking server, described person liable's qualification data comprise hospital's membership information, doctor's membership information and insured people's membership information;
Step S13, verification unit is by information for hospital and hospital's membership information contrast, if two kinds of information unanimously perform step S14, if two kinds of inconsistent S17 that perform step of information;
Step S14, verification unit is by information about doctor and the contrast of doctor's membership information, if two kinds of information unanimously perform step S15, if two kinds of inconsistent S17 that perform step of information;
Step S15, verification unit is by insured people's information and the contrast of insured people's membership information, if two kinds of information unanimously perform step S16, if two kinds of inconsistent S17 that perform step of information;
Step S16, check results output unit generates the effective conclusion of reimbursement document data;
Step S17, check results output unit generates reimbursement document data conclusion in violation of rules and regulations.
3. medical insurance reimbursement qualification method of calibration as claimed in claim 2, is characterized in that, described verification unit is by person liable's qualification data of Webservice interface or the storage of DB interface interchange server memory.
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| CN201410389301.8A CN104133810A (en) | 2014-08-08 | 2014-08-08 | System and method for verifying medical insurance reimbursement qualification |
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Cited By (20)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN105159948A (en) * | 2015-08-12 | 2015-12-16 | 成都数联易康科技有限公司 | Medical insurance fraud detection method based on multiple features |
| CN106487901A (en) * | 2016-10-18 | 2017-03-08 | 郑州云海信息技术有限公司 | A kind of social security submits an expense account system and method |
| CN107256338A (en) * | 2017-06-08 | 2017-10-17 | 湖南暄程科技有限公司 | A kind of hospital self-service method of charging out and system |
| CN107729376A (en) * | 2017-09-13 | 2018-02-23 | 平安科技（深圳）有限公司 | Insurance data checking method, device, computer equipment and storage medium |
| CN108255793A (en) * | 2017-11-22 | 2018-07-06 | 中国平安财产保险股份有限公司 | A kind of information verification method and terminal device |
| CN108305176A (en) * | 2018-01-05 | 2018-07-20 | 上海栈略数据技术有限公司 | A kind of optimization medical care insurance intelligent checks system based on reaction type machine learning |
| CN109492829A (en) * | 2018-12-13 | 2019-03-19 | 平安医疗健康管理股份有限公司 | Medical insurance fund expenditure prediction technique and relevant apparatus based on artificial intelligence |
| CN109493966A (en) * | 2018-10-27 | 2019-03-19 | 平安医疗健康管理股份有限公司 | A kind of hypertension authentication method and relevant device based on data processing |
| CN109523393A (en) * | 2018-10-22 | 2019-03-26 | 平安医疗健康管理股份有限公司 | It is a kind of to audit the providing method serviced and device and computer equipment |
| CN109522743A (en) * | 2018-10-27 | 2019-03-26 | 平安医疗健康管理股份有限公司 | A kind of medical insurance bill auditing method, block chain node device and system |
| CN109522387A (en) * | 2018-10-27 | 2019-03-26 | 平安医疗健康管理股份有限公司 | Lumbar vertebra protrusion quality certification method, equipment and server based on data processing |
| CN109545369A (en) * | 2018-10-27 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Diabetes quality certification method, equipment and server based on data processing |
| CN109544372A (en) * | 2018-10-30 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Outpatient service chronic disease qualification monitoring method and relevant apparatus based on artificial intelligence |
| CN109544368A (en) * | 2018-10-27 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Marrow proliferative disease quality certification method, equipment, server and readable medium |
| CN109542923A (en) * | 2018-05-28 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Core protects method, apparatus, computer equipment and storage medium |
| CN109615204A (en) * | 2018-11-30 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Method for evaluating quality, device, equipment and the readable storage medium storing program for executing of medical data |
| CN109615542A (en) * | 2018-12-13 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Submit an expense account processing method, device, equipment and computer readable storage medium |
| CN110084562A (en) * | 2019-04-10 | 2019-08-02 | 宿迁学院产业技术研究院 | A kind of colleges and universities render an account system |
| CN112634065A (en) * | 2020-12-21 | 2021-04-09 | 山东众阳健康科技集团有限公司 | Method and system for reimbursing remote medical care receipt |
| CN113870986A (en) * | 2021-09-29 | 2021-12-31 | 北京中电普华信息技术有限公司 | An information management system for employee medical security |
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| CN105159948A (en) * | 2015-08-12 | 2015-12-16 | 成都数联易康科技有限公司 | Medical insurance fraud detection method based on multiple features |
| CN105159948B (en) * | 2015-08-12 | 2019-04-02 | 成都数联易康科技有限公司 | A kind of Medicare fraud detection method based on multiple features |
| CN106487901A (en) * | 2016-10-18 | 2017-03-08 | 郑州云海信息技术有限公司 | A kind of social security submits an expense account system and method |
| CN107256338A (en) * | 2017-06-08 | 2017-10-17 | 湖南暄程科技有限公司 | A kind of hospital self-service method of charging out and system |
| CN107729376A (en) * | 2017-09-13 | 2018-02-23 | 平安科技（深圳）有限公司 | Insurance data checking method, device, computer equipment and storage medium |
| CN107729376B (en) * | 2017-09-13 | 2020-03-17 | 平安科技（深圳）有限公司 | Insurance data auditing method and device, computer equipment and storage medium |
| CN108255793A (en) * | 2017-11-22 | 2018-07-06 | 中国平安财产保险股份有限公司 | A kind of information verification method and terminal device |
| CN108305176A (en) * | 2018-01-05 | 2018-07-20 | 上海栈略数据技术有限公司 | A kind of optimization medical care insurance intelligent checks system based on reaction type machine learning |
| CN109542923A (en) * | 2018-05-28 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Core protects method, apparatus, computer equipment and storage medium |
| CN109542923B (en) * | 2018-05-28 | 2023-06-16 | 深圳平安医疗健康科技服务有限公司 | Nuclear protection method, device, computer equipment and storage medium |
| CN109523393A (en) * | 2018-10-22 | 2019-03-26 | 平安医疗健康管理股份有限公司 | It is a kind of to audit the providing method serviced and device and computer equipment |
| CN109493966A (en) * | 2018-10-27 | 2019-03-19 | 平安医疗健康管理股份有限公司 | A kind of hypertension authentication method and relevant device based on data processing |
| CN109522387B (en) * | 2018-10-27 | 2023-07-14 | 平安医疗健康管理股份有限公司 | Lumbar disc herniation qualification authentication method, equipment and server based on data processing |
| CN109544368A (en) * | 2018-10-27 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Marrow proliferative disease quality certification method, equipment, server and readable medium |
| CN109545369A (en) * | 2018-10-27 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Diabetes quality certification method, equipment and server based on data processing |
| CN109522387A (en) * | 2018-10-27 | 2019-03-26 | 平安医疗健康管理股份有限公司 | Lumbar vertebra protrusion quality certification method, equipment and server based on data processing |
| CN109493966B (en) * | 2018-10-27 | 2024-06-25 | 平安医疗健康管理股份有限公司 | Hypertension authentication method based on data processing and related equipment |
| CN109522743A (en) * | 2018-10-27 | 2019-03-26 | 平安医疗健康管理股份有限公司 | A kind of medical insurance bill auditing method, block chain node device and system |
| CN109522743B (en) * | 2018-10-27 | 2023-08-22 | 平安医疗健康管理股份有限公司 | Medical insurance bill auditing method, block chain link point equipment and system |
| CN109544372A (en) * | 2018-10-30 | 2019-03-29 | 平安医疗健康管理股份有限公司 | Outpatient service chronic disease qualification monitoring method and relevant apparatus based on artificial intelligence |
| CN109544372B (en) * | 2018-10-30 | 2024-04-09 | 平安医疗健康管理股份有限公司 | Artificial intelligence-based outpatient chronic disease qualification monitoring method and related device |
| CN109615204A (en) * | 2018-11-30 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Method for evaluating quality, device, equipment and the readable storage medium storing program for executing of medical data |
| CN109615204B (en) * | 2018-11-30 | 2023-02-03 | 平安医疗健康管理股份有限公司 | Quality evaluation method, device and equipment of medical data and readable storage medium |
| CN109492829A (en) * | 2018-12-13 | 2019-03-19 | 平安医疗健康管理股份有限公司 | Medical insurance fund expenditure prediction technique and relevant apparatus based on artificial intelligence |
| CN109615542A (en) * | 2018-12-13 | 2019-04-12 | 平安医疗健康管理股份有限公司 | Submit an expense account processing method, device, equipment and computer readable storage medium |
| CN110084562A (en) * | 2019-04-10 | 2019-08-02 | 宿迁学院产业技术研究院 | A kind of colleges and universities render an account system |
| CN112634065A (en) * | 2020-12-21 | 2021-04-09 | 山东众阳健康科技集团有限公司 | Method and system for reimbursing remote medical care receipt |
| CN113870986A (en) * | 2021-09-29 | 2021-12-31 | 北京中电普华信息技术有限公司 | An information management system for employee medical security |
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