WO2020119109A1 - Reimbursement processing method and device, terminal and computer-readable storage medium - Google Patents

Abstract

A reimbursement processing method and device, a terminal and a computer-readable storage medium. The reimbursement processing method comprises the steps of: obtaining a preset reimbursement limit and experience data (S101); analyzing the experience data and predicting the morbidity of chronic myeloid leukemia of a target city according to an analysis result (S102); using the product of the morbidity and a preset utilization rate adjustment coefficient as a utilization rate (S103); using the product of the reimbursement limit and the utilization rate as a risk premium (S104); using the product of the risk premium and a preset pricing adjustment coefficient as the premium of the specific medicine corresponding to the reimbursement limit (S105); determining whether the symptoms of an insured person are chronic myeloid leukemia and such person is an Imatinib drug-resistant patient (S106); and if yes, generating reimbursement suggestions according to the reimbursement limit and medical consultation data of the insured person (S107). According to the present technical solution, the morbidity is obtained by collecting and analyzing the experience data by means of a big data analysis method, and the premium and the reimbursement suggestions for the specific medicine may be obtained merely by inputting the reimbursement amount and the experience data.

Description

Reimbursement processing method, device, terminal and computer readable storage medium The

This application requires the priority of the Chinese patent application submitted to the Chinese Patent Office on December 13, 2018, with the application number 201811529186.4 and the invention titled "reimbursement processing method, device, terminal and computer-readable storage medium". The reference is incorporated in the application.

Technical field

This application relates to the field of medical insurance, in particular to a method, device, terminal and computer-readable storage medium for reimbursement processing.

Background technique

At present, there are two specific drugs for chronic myeloid leukemia on the market, dasatinib and nilotinib. Due to the good therapeutic effect, the use of these two specific drugs is also increasing, and these two Special medicines are expensive, and in order to reduce the burden on patients, it is urgent to include these two special medicines in the category of medical insurance. If the medical insurance participant needs to get the reimbursement of the special effect medicine, the medical insurance management unit needs to determine the premium corresponding to the reimbursement amount first, and then reimburse the corresponding cost to the insured according to the reimbursement amount corresponding to the premium paid by the insured person. Then, in the prior art, the premiums corresponding to the reimbursement amount need to be collected by experts, and the results can only be obtained after a comprehensive analysis. The efficiency is low and the human factors are large, and the reimbursement of expenses to the insured needs to be performed by the staff on the claim information Audit, large workload and low efficiency. The

Summary of the invention

The main purpose of this application is to provide a method, device, terminal, computer-readable storage medium and computer-readable storage medium for reimbursement processing, aiming to solve the process of determining the premium corresponding to the reimbursement amount of special-effect medicines and the low efficiency in the reimbursement process of special-effect medicines , Large workload, low efficiency technical issues.

In order to achieve the above object, the present application provides a reimbursement processing method for processing the reimbursement of special-effect drugs for treating chronic myeloid leukemia. The reimbursement processing method includes the steps of:

Obtain preset reimbursement amount and empirical data, the empirical data includes the economic, cultural, medical development level of the target city and the total population of the city of the same type as the target city and the annual incidence of chronic myeloid leukemia;

Analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results;

Taking the product of the incidence rate and the preset utilization rate adjustment coefficient as the utilization rate of the specific effect drug;

Take the product of the reimbursement amount and the utilization rate as the risk premium;

Taking the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect drug;

Obtain the medical information of the insured person, and determine whether the condition of the insured person is chronic myeloid leukemia and imatinib-resistant patients according to the medical information of the insured person;

If the disease suffered by the insured person is chronic myelogenous leukemia and is imatinib-resistant patient, obtain the reimbursement amount corresponding to the premium paid by the insured person, based on the reimbursement amount and the The insured's medical information generates reimbursement suggestions.

The present application also provides a reimbursement processing device for processing the reimbursement of special effects medicine for treating chronic myeloid leukemia. The reimbursement processing device includes the steps of:

A first acquisition module, the first acquisition module is used to acquire preset reimbursement quota and experience data, the experience data includes the economic, cultural, medical development level of the target city and the total of the cities of the same type as the target city Population and annual incidence of chronic myeloid leukemia;

A prediction module, the prediction module is used to analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city according to the analysis result;

A first calculation module, the first calculation module is configured to use the product of the morbidity rate and a preset utilization rate adjustment coefficient as the utilization rate of the special effect medicine;

A second calculation module, the second calculation module is used to take the product of the reimbursement amount and the utilization rate as the risk premium;

A third calculation module, the third calculation module is configured to use the product of the risk premium and a preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect drug;

Judgment module, the judgment module is used to obtain the medical information of the insured person, and determine whether the disease suffered by the insured person is chronic myeloid leukemia and imatinib resistance according to the medical information of the insured person Sexual patients

An execution module, the execution module is used to obtain a reimbursement amount corresponding to the premium paid by the insured when the insured suffers from a chronic myeloid leukemia and is imatinib-resistant patient , Generate reimbursement suggestions based on the reimbursement amount and the medical information of the insured person.

The present application also provides an apparatus including a processor, a memory, and computer-readable instructions stored on the memory and executable by the processor, wherein the computer-readable instructions are executed by the processor During execution, the steps of any of the reimbursement processing methods described above are implemented.

The present application also provides a computer-readable storage medium having computer-readable instructions stored on the computer-readable storage medium, wherein when the computer-readable instructions are executed by a processor, the reimbursement process described in any one of the above can be realized Method steps.

BRIEF DESCRIPTION

FIG. 1 is a schematic diagram of a hardware structure of a device involved in a solution of an embodiment of this application;

FIG. 2 is a schematic flowchart of a first embodiment of a reimbursement processing method of this application.

The implementation, functional characteristics and advantages of the present application will be further described in conjunction with the embodiments and with reference to the drawings.

detailed description

It should be understood that the specific embodiments described herein are only used to explain the present application, and are not used to limit the present application.

The reimbursement processing method involved in the embodiments of the present application is mainly applied to a terminal, and the terminal may be a computer, a mobile terminal, and other devices with processing functions.

Referring to FIG. 1, FIG. 1 is a schematic structural diagram of a terminal involved in a solution according to an embodiment of this application. In the embodiment of the present application, the terminal may include a processor 1001 (for example, a CPU), a communication bus 1002, a user interface 1003, a network interface 1004, and a memory 1005. Among them, the communication bus 1002 is used to realize the connection and communication between these components; the user interface 1003 may include a display (Display), an input unit such as a keyboard (Keyboard); the network interface 1004 may optionally include a standard wired interface, a wireless interface (Such as WI-FI interface); the memory 1005 can be a high-speed RAM memory or a stable memory (non-volatile memory), such as a disk storage, the storage 1005 may optionally be a storage device independent of the foregoing processor 1001.

Those skilled in the art may understand that the hardware structure shown in FIG. 1 does not constitute a limitation on the terminal, and may include more or less components than those illustrated, or combine certain components, or arrange different components.

With continued reference to FIG. 1, the memory 1005 in FIG. 1 as a computer-readable storage medium may include an operating system, a network communication module, and computer-readable instructions.

In FIG. 1, the network communication module is mainly used to connect to the server and perform data communication with the server; and the processor 1001 can call computer-readable instructions stored in the memory 1005 and perform the steps of the following reimbursement processing method.

Based on the hardware structure of the above device, various embodiments of the reimbursement processing method of the present application are proposed.

This application provides a reimbursement processing method.

Please refer to FIG. 2. In an embodiment of the present application, the reimbursement processing method includes the following steps:

S101: Obtain preset reimbursement quota and empirical data. The empirical data includes the economic, cultural, medical development level of the target city and the total population of the city of the same type as the target city and the annual incidence of chronic myeloid leukemia;

The specific drug of the embodiment of the present application may be dasatinib tablets and/or nilotinib capsules, the brand name of dasatinib tablets is dardar, and the brand name of nilotinib is dasina. Dasatinib and nilotinib are both specific drugs for the treatment of chronic myeloid leukemia. In order to include the two drugs Nilotinib and Dasatinib into the medical insurance of the target city, it is necessary to determine the premiums of the specific drugs first. Determining premiums requires reference to empirical data to predict the incidence of chronic myeloid leukemia in target cities. Cities of the same type refer to cities with similar industrial structure, close geographic location, and similar climate and environment to the target city. The empirical data includes the economic, cultural, medical development level of the target city and the total population of the city of the same type as the target city and the annual incidence of chronic myeloid leukemia. The actuarial method of loss distribution can be used to collect the same The historical data of the city, and determine the incidence of chronic myeloid leukemia in the same city type as the target city based on the historical data. The average annual incidence of chronic myeloid leukemia in the past three years can be used as the annual incidence of chronic myeloid leukemia. The economic, cultural and medical development level of the target city can be evaluated based on the per capita GDP of the target city, the total GDP, the proportion of the resident population at all levels of education, the number and level of hospitals. The reimbursement processing method of this embodiment can be executed by the device. The device is connected to the memory of the server, and the server stores the experience data provided by the medical insurance management unit. Experience data can be collected by the medical insurance management unit.

S102: Analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results;

Because the cities with the same type as the target city have similar industrial structures, geographical locations, and similar climate environments, that is, similar living environments, and the physical fitness of the residents in the two cities is similar, then the incidence of cities of the same type as the target city can be As a reference value for the incidence rate in the target city, it is used to predict the incidence rate in the target city. Because patients with chronic myeloid leukemia may not be able to go to the hospital due to economic, cultural and medical conditions, they may not be able to find out that they have contracted chronic myeloid leukemia in time, so you need to refer to the target city's economy, culture, and medical treatment. Development level, economic, cultural and medical development level.

S103: Use the product of the incidence rate and the preset utilization rate adjustment coefficient as the utilization rate of the special effect medicine;

The incidence rate reflects the proportion of people with chronic myeloid leukemia. The incidence rate also needs to take into account the growth rate of the disease and the disease life cycle. As time goes on, the number of patients will increase, and patients with chronic myeloid leukemia will also It may die due to the deterioration of the condition, which affects the proportion of people with chronic myeloid leukemia and thus affects the use rate of specific drugs. Therefore, it is necessary to determine the preset utilization rate adjustment coefficient according to the disease survival growth rate and the disease life cycle, and multiply the predicted morbidity by the preset utilization rate adjustment coefficient to obtain the utilization rate of the specific drug.

Specifically, the preset usage rate adjustment coefficient may be determined before step S103. The incidence adjustment factor can be determined according to the disease life cycle and natural growth rate of chronic myeloid leukemia in the same city as the target city type in the empirical data; then the incidence adjustment factor and (1 + preset additional risk factor The product of occurrence rate) is used as the utilization rate adjustment factor. Due to economic, cultural and medical constraints, patients with chronic myeloid leukemia may not always use dasatinib tablets or nilotinib capsules, and additional risk factors can be determined according to the economic, cultural and medical development level of the target city Incidence rate to make the calculated usage rate more accurate. The preset additional risk factor occurrence rate may be preset by the staff of the medical insurance management unit before step S103, for example, it may be set to 20%.

S104: Use the product of reimbursement amount and utilization rate as risk premium;

There are multiple reimbursement quotas for medical insurance for special effects medicines. For each reimbursement quota, a corresponding premium shall be determined. When reimbursement is required, the corresponding reimbursement quota shall be determined according to the premium paid by the insured, and the reimbursement shall be made according to the reimbursement quota. The product of the reimbursement amount, utilization rate and total population of the target city is the predicted total reimbursement cost of the target city in one year. Divide the total cost by the total population of the target city is the predicted reimbursement cost per capita. The per capita reimbursement cost required is regarded as the risk premium, and the product of the reimbursement amount and utilization rate is also taken as the risk premium.

S105: Use the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount for the special-effect medicine;

In addition to risk premiums, the cost of medical insurance for special-effect medicines also needs to consider operating expenses and taxes, and in some cases, profits need to be considered. Therefore, the preset pricing adjustment factor can be determined according to operating expenses, tax proportion and target profit rate , And then take the product of the risk premium and the preset pricing adjustment factor as the premium.

Specifically, before step S105, a preset pricing adjustment coefficient may be determined. You can first obtain the operating expense adjustment factor, tax rate and target profit rate; then calculate the preset pricing adjustment factor according to the following algorithm:

The preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate). The operating cost adjustment factor can be determined by the management unit of the medical insurance for specific drugs according to the actual operating cost, the tax rate can be determined according to the relevant national tax and fee policies, and the target profit rate can be set by the medical insurance management unit according to actual needs. , You can set the target profit margin to 0.

After the premium is determined, the premium of the special effect drug can be saved, so that the next time the reimbursement of the special effect drug is processed, the premium of the special effect drug can be directly called.

S106: Obtain the medical information of the insured person, and determine whether the disease suffered by the insured person is chronic myeloid leukemia and imatinib-resistant patients according to the medical information of the insured person;

Special medicine is used to treat chronic myeloid leukemia, and can be used to treat patients who are resistant to imatinib. Imatinib can also be used to treat chronic myeloid leukemia, because imatinib can also be used to treat As a special drug for chronic myelogenous leukemia, and the market price is lower than dasatinib tablets and nilotinib capsules, patients with chronic myeloid leukemia and imatinib resistance are used as reimbursement standards. During the review process, the insured person submits medical information and reimbursement application, the device judges whether the insured person's condition is chronic myeloid leukemia based on the insured patient's medical information, and whether the insured person is resistant to imatinib Medicinal.

S107: If the insured suffers from chronic myeloid leukemia and is imatinib-resistant, obtain the reimbursement amount corresponding to the premium paid by the insured person, based on the reimbursement amount and the medical information of the insured person Generate reimbursement suggestions.

When the insured person’s condition is chronic myeloid leukemia and is imatinib-resistant, it means that the insured person meets the requirements of the reimbursement standard, then obtain the insurance fee paid by the insured person, according to The premium paid by the insured person determines the premium of the insured, determines the corresponding reimbursement amount according to the premium, and then generates a reimbursement recommendation based on the reimbursement amount and the insured's medical information, so that the medical insurance management unit can receive the reimbursement recommendation based on the medical information Re-confirm that the insured person meets the requirements of the reimbursement standard. If it meets the requirements, the reimbursement amount can be determined according to the insurance premium paid by the insured person and the insured person's special-effect drug expenses can be reimbursed according to the reimbursement amount.

In the above technical solution, obtain the preset reimbursement amount and empirical data, analyze the empirical data, and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results; the product of the incidence and the preset utilization rate adjustment coefficient is taken as The use rate of special-purpose drugs; the product of the reimbursement amount and utilization rate as the risk premium; the product of the risk premium and the preset pricing adjustment coefficient as the premium of the special-effect drug corresponding to the reimbursement amount; obtain the medical information of the insured, according to the parameters The insured's medical information to determine whether the insured's condition is chronic myelogenous leukemia and imatinib-resistant patients; if the insured's condition is chronic myeloid leukemia and imatinib resistance For drug patients, the reimbursement amount corresponding to the premium paid by the insured person is obtained, and a reimbursement proposal is generated based on the reimbursement amount and the medical information of the insured person. In this way, when the medical insurance management unit handles the reimbursement of special effects drugs, it only needs to enter the reimbursement amount and empirical data to get the premiums and reimbursement suggestions for special effects drugs, and can decide whether to reimburse the cost of the special effects drugs applied for by the insured person according to the reimbursement suggestions. , Which reduces the workload and helps improve work efficiency. Moreover, after the premium for the first-in-class drugs is obtained for the first time, the premium for the special-effect drugs can be saved. The next time the staff of the medical insurance management unit handles the reimbursement, there is no need to calculate the premium again, which is convenient for the medical insurance management unit to handle the reimbursement of the cost of the special-effect drugs. Further reduce the workload and improve work efficiency.

It should be noted that, the device in the embodiment of the present application may be a server or a terminal. That is to say, the reimbursement processing method of the embodiment of the present application may be executed by the terminal or the server. When executed by the server, the server may be connected to multiple terminals. The multiple terminals may include a first terminal for the medical insurance management unit and a second terminal for the applicant to submit an application for reimbursement. The server may first perform steps S101-S105 to calculate Insurance premium; then the insured person applying for reimbursement uploads the medical information to the server through the second terminal. The server obtains the medical information of the insured person from the second terminal and executes step S106 to determine whether the disease suffered by the insured person is chronic. Leukemia and imatinib-resistant patients, and then execute step S107, after generating the reimbursement proposal, send the reimbursement application and the reimbursement proposal to the first terminal, and the staff of the medical insurance management unit will review the reimbursement application according to the reimbursement proposal.

Based on the above embodiment, in another embodiment of the present application, the premium includes the first-year premium and the non-first-year premium. Before step S105, the reimbursement processing method further includes the steps:

S108: Analyze the usage data of competitive products in the empirical data to obtain the distribution factor of competitive products;

Dasatinib tablets and nilotinib capsules may have two competitive drugs with the same disease type and similar therapeutic effects (ie, competing products). When calculating the premium, you need to consider the impact of competing products, so you need to calculate The allocation factor of competitive products. Competitive product allocation coefficient is greater than 0 and less than or equal to 1. If there is no competitive product, the competitive product allocation coefficient is 1.

S109: Obtain the adjustment coefficient of operating expenses, the proportion of taxes and fees and the target profit rate;

Operating expenses and taxes are both part of the cost of medical insurance, and premiums also need to include the target profit. Therefore, the operating cost adjustment factor, tax rate and target profit rate are used to calculate insurance borrowing to make the final premium more accurate. Avoid medical insurance losses for specific drugs.

S110: Calculate the preset price adjustment coefficient for the first year according to the following algorithm:

The preset pricing adjustment factor for the first year = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate) * competitive product allocation factor;

S111: Calculate the default pricing adjustment coefficient for the non-first year according to the following algorithm:

Non-first-year preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate);

The operating cost adjustment factor can be determined by the management unit of the medical insurance for specific drugs according to the actual operating cost, the tax rate can be determined according to the relevant national tax and fee policies, and the target profit rate can be set by the medical insurance management unit according to actual needs. , You can set the target profit margin to 0.

Step S105 includes:

S1051: Use the product of the risk premium and the first-year preset pricing adjustment coefficient as the first-year premium corresponding to the reimbursement amount for the special-effect medicine;

S1052: The product of the risk premium and the non-first-year preset pricing adjustment coefficient is taken as the non-first-year premium of the special-effect medicine corresponding to the reimbursement amount.

Due to the existence of competing drugs, customers can be attracted to participate in insurance by appropriately reducing the premium for the first year. This helps to enhance the competitiveness of medical insurance for specific drugs.

It should be noted that steps S108-S111 are performed between steps S104 and S105. In other embodiments, steps S108-S111 are not limited to being performed between steps S104 and S105, but may also be performed between steps S103 and S104, It can also be performed between steps S102 and S103, or between steps S101 and S102.

Based on the above embodiment, in yet another embodiment of the present application, the premium includes A insurance premium and B insurance premium, and step S105 includes:

S1053: The product of the risk premium, the preset pricing adjustment factor and the preset A insurance weight is used as the A insurance premium corresponding to the special effect medicine and the reimbursement amount;

S1054: The product of the risk premium, the preset pricing adjustment coefficient and the preset B insurance weight is used as the B insurance premium corresponding to the special effect medicine and the reimbursement amount;

S1055: Set the sum of A insurance premium and B insurance premium as the premium.

Medical insurance is divided into different types, and different types of reimbursement ratios are different. For example, existing medical insurance includes urban residents medical insurance and employee medical insurance. The reimbursement ratio of urban residents' medical insurance is lower than that of employee medical insurance. In determining the premium, the weight of the two types of insurance needs to be considered. Therefore, the product of the risk premium, the preset pricing adjustment factor and the preset A insurance weight is used as the A insurance premium corresponding to the special effect medicine and the reimbursement amount, and the product of the risk premium, the preset pricing adjustment coefficient and the preset B insurance weight As the B-insurance premium corresponding to the reimbursement amount of the special-effect medicine, the sum of the A-insurance premium and the B-insurance premium is set as the premium, so that the premium obtained is more accurate, and the medical insurance loss of the special-effect medicine is avoided. Among them, A insurance weight and B insurance weight can be determined according to the current medical insurance A and B reimbursement ratio.

Based on the above embodiment, the medical information includes the medical history of the insured person, bone marrow aspiration pathology report, and medication records. Step S106 includes:

S1061: Determine whether the condition recorded in the medical record is chronic myeloid leukemia, and if the condition recorded in the medical record is chronic myeloid leukemia, obtain a bone marrow aspiration pathology report of the insured person;

The illness recorded in the medical record may not necessarily be the actual illness of the insured person, the doctor may collude with the insured person, fill in the chronic myeloid leukemia in the medical record when the insured person does not have chronic myeloid leukemia, so that the insured person Use medical insurance to buy special effects medicines at low prices. In order to avoid this situation, when the condition recorded in the medical record is chronic myeloid leukemia, it is necessary to obtain the insured person's bone marrow aspiration pathology report to further determine whether the insured person actually has chronic myeloid leukemia. When the disease recorded in the case is not chronic myeloid leukemia, the applicant's reimbursement application is returned.

S1062: According to the analysis of the insured person's bone marrow aspiration pathology report, the insured person's actual disease is obtained, and whether the actual disease is chronic myeloid leukemia is determined;

According to the bone marrow aspiration pathology report, determine whether the data on the bone marrow aspiration meets the requirements of chronic myeloid leukemia. If it meets, the actual condition is determined to be chronic myeloid leukemia; if it does not meet, the applicant's reimbursement application is returned .

S1063: If the actual disease is chronic myelogenous leukemia, determine whether the insured person is an imatinib-resistant patient according to the medication records.

According to the medication record, it can be judged whether there is a medication record of imatinib, and whether it is a drug-resistant patient of imatinib is determined according to the therapeutic effect after medication in the medication record. If the insured person is an imatinib-resistant patient, step S107 is executed. If the insured person is not an imatinib-resistant patient, the insured person's reimbursement application will be returned.

Based on the above embodiment, step S1062 further includes steps:

S10621: determine whether the provider of the bone marrow aspiration pathology report is a hospital below grade three;

In order to more accurately determine the actual illness of the insured, the reliability of the pathological report of bone marrow aspiration must be ensured. The accuracy of the bone marrow aspiration pathology report can be determined by judging whether the provider of the bone marrow aspiration pathology report is a third-grade or below hospital to determine whether the bone marrow aspiration pathology report is reliable.

If the provider of the bone marrow aspiration pathology report is a hospital below grade three, it can be determined that the bone marrow aspiration pathology report is unreliable, and step S10622 is performed: obtaining the BCR/ABL fusion gene test result of the insured person, and determining whether the BCR/ABL fusion gene test result is Meet the preset requirements. The preset requirements are determined based on the BCR/ABL fusion gene of patients with chronic myeloid leukemia. Therefore, whether the actual disease of the insured person is chronic myeloid leukemia can be determined by judging whether the BCR/ABL fusion gene test results meet the preset requirements. .

S10623: If the result of the BCR/ABL fusion gene test meets the preset requirements, it is determined that the actual disease is chronic myeloid leukemia. If the result of the BCR/ABL fusion gene test does not meet the preset requirements, it is determined that the actual disease is not chronic myeloid leukemia.

If the provider of the bone marrow aspiration pathology report is a Class III or above hospital, the bone marrow aspiration pathology report is reliable, and it can be directly determined whether the insured's actual illness is chronic myeloid leukemia based on the results of the bone marrow aspiration pathology report.

In this way, when the insured's bone marrow aspiration pathology report is issued for a hospital below grade three, when the insured submits an application for reimbursement, it is also necessary to provide the BCR/ABL fusion genetic test results, which can improve the accuracy of the audit and reduce medical insurance work. The manual work load of personnel.

In addition, the present application also provides a reimbursement processing device. The special effect medicine is used to treat chronic myeloid leukemia. The reimbursement processing device includes:

The first acquisition module is used to obtain preset reimbursement quota and empirical data. The empirical data includes the economic, cultural, medical development level of the target city and the total population and annual chronic marrow of the city of the same type as the target city The incidence of sexual leukemia;

The prediction module is used to analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results;

A first calculation module, the first calculation module is used to use the product of the incidence rate and the preset utilization rate adjustment coefficient as the utilization rate of the special effect medicine;

A second calculation module, the second calculation module is used to take the product of the reimbursement amount and utilization rate as the risk premium;

A third calculation module, the third calculation module is used to take the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine;

Judgment module, which is used to obtain the medical information of the insured, and to determine whether the disease suffered by the insured is chronic myeloid leukemia and imatinib-resistant patients according to the medical information of the insured;

The execution module is used to obtain the reimbursement amount corresponding to the premium paid by the insured person when the insured person’s condition is chronic myeloid leukemia and imatinib-resistant patients. The insurer's medical information generates reimbursement recommendations.

Further, the reimbursement processing device further includes:

The first analysis module is used to determine the adjustment coefficient of the incidence rate based on the life cycle of the chronic myeloid leukemia and the natural growth rate of the disease in the city of the same type of target city in the empirical data;

The fourth calculation module is configured to use the product of the incidence adjustment factor and (1+preset additional risk factor occurrence rate) as the utilization rate adjustment factor.

Further, the reimbursement processing device further includes:

The third acquisition module is used to acquire the adjustment coefficient of operating expenses, the proportion of taxes and fees and the target profit rate;

The fifth calculation module is used to calculate the preset pricing adjustment coefficient according to the following algorithm:

The preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate).

Further, the premium includes first-year premium and non-first-year premium. The preset pricing adjustment factor includes the first-year preset pricing adjustment coefficient and the non-first-year preset pricing adjustment coefficient. The reimbursement processing device also includes:

The second analysis module is used to analyze the competitive data usage data in the empirical data to obtain the competitive product allocation coefficient;

The fourth acquisition module is used to acquire the adjustment coefficient of operating expenses, the proportion of taxes and fees and the target profit rate;

The sixth calculation module is used to calculate the preset price adjustment coefficient for the first year according to the following algorithm:

The preset pricing adjustment factor for the first year = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate) * competitive product allocation factor;

The seventh calculation module is used to calculate the preset pricing adjustment coefficient for the non-first year according to the following algorithm:

Non-first-year preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate);

The third calculation module includes:

The first calculation unit is used to take the product of the risk premium and the first-year preset pricing adjustment coefficient as the first-year premium corresponding to the reimbursement amount of the special-effect medicine;

The second calculation unit is used to take the product of the risk premium and the non-first-year preset pricing adjustment coefficient as the non-first-year premium of the special-effect medicine corresponding to the reimbursement amount.

Further, the premium includes insurance premium A and insurance premium B, and the third calculation module includes:

The third calculation unit is used to take the product of the risk premium, the preset pricing adjustment coefficient and the preset A insurance weight as the A insurance premium corresponding to the special effect medicine and the reimbursement amount;

The fourth calculation unit is used to take the product of the risk premium, the preset pricing adjustment coefficient and the preset B insurance weight as the B insurance premium corresponding to the special effect medicine and the reimbursement amount;

The fifth calculation unit is used to set the sum of A insurance premiums and B insurance premiums as premiums.

Further, the medical information includes the medical history of the insured person, bone marrow aspiration pathology report and medication records, and the judgment module includes:

The obtaining unit is used to judge whether the condition recorded in the medical record is chronic myeloid leukemia, and if the condition recorded in the medical record is chronic myeloid leukemia, obtain the bone marrow aspiration pathology report of the insured person;

The first judgment unit is used to obtain the actual disease of the insured person based on the analysis of the insured person's bone marrow aspiration pathology and determine whether the actual disease is chronic myeloid leukemia;

The second judgment unit is used to judge whether the insured person is an imatinib-resistant patient according to the medication record when the actual disease is chronic myeloid leukemia.

Further, the first judgment unit includes:

The first judgment subunit is used to judge whether the provider of the bone marrow aspiration pathology report is a hospital below grade three;

The second judgment subunit is used to obtain the BCR/ABL fusion gene test result of the insured person and determine whether the BCR/ABL fusion gene test result meets the preset requirements when the provider of the bone marrow aspiration pathology report is a hospital below grade three ;

The determination subunit is used to determine that the actual disease is chronic myeloid leukemia when the BCR/ABL fusion gene test result meets the preset requirements.

Wherein, the function realization of each module in the above reimbursement processing device corresponds to each step in the above embodiment of the reimbursement processing method, and its function and implementation process will not be repeated here one by one.

In addition, the present application further provides a computer-readable storage medium, and the computer-readable storage medium may be a non-volatile readable storage medium.

The computer-readable storage medium of the present application stores computer-readable instructions. When the computer-readable instructions are executed by a processor, the steps of the reimbursement processing method as in any of the foregoing embodiments are implemented.

For the method implemented when the computer-readable instructions are executed, reference may be made to various embodiments of the reimbursement processing method of the present application, and details are not described herein again.

It should be noted that in this article, the terms "include", "include" or any other variant thereof are intended to cover non-exclusive inclusion, so that a process, method, article or system that includes a series of elements includes not only those elements, It also includes other elements that are not explicitly listed, or include elements inherent to this process, method, article, or system. Without more restrictions, the element defined by the sentence "include one..." does not exclude that there are other identical elements in the process, method, article or system that includes the element.

The sequence numbers of the above embodiments of the present application are for description only, and do not represent the advantages and disadvantages of the embodiments.

Through the description of the above embodiments, those skilled in the art can clearly understand that the methods in the above embodiments can be implemented by means of software plus a necessary general hardware platform, and of course, can also be implemented by hardware, but in many cases the former is better Implementation. Based on this understanding, the technical solution of the present application can be embodied in the form of a software product in essence or part that contributes to the existing technology, and the computer software product is stored in a storage medium (such as ROM/RAM as described above) , Magnetic disk, optical disk), including several instructions to make a terminal device (which can be a mobile phone, computer, server, air conditioner, or network equipment, etc.) to perform the method described in each embodiment of the present application.

The above are only the preferred embodiments of the present application, and do not limit the scope of the patent of the present application. Any equivalent structure or equivalent process transformation made by the description and drawings of this application, or directly or indirectly used in other related technical fields , The same reason is included in the scope of patent protection in this application.

Claims (20)

A reimbursement processing method is used to deal with the reimbursement of special-effect medicines, which are used to treat chronic myeloid leukemia, characterized in that the reimbursement processing method includes the steps of: Obtain preset reimbursement amount and empirical data, the empirical data includes the economic, cultural, medical development level of the target city and the total population of the city of the same type as the target city and the annual incidence of chronic myeloid leukemia; Analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results; Taking the product of the incidence rate and the preset utilization rate adjustment coefficient as the utilization rate of the specific effect drug; Take the product of the reimbursement amount and the utilization rate as the risk premium; Taking the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect drug; Obtain the medical information of the insured person, and determine whether the condition of the insured person is chronic myeloid leukemia and imatinib-resistant patients according to the medical information of the insured person; If the disease suffered by the insured person is chronic myelogenous leukemia and is imatinib-resistant patient, obtain the reimbursement amount corresponding to the premium paid by the insured person, based on the reimbursement amount and the The insured's medical information generates reimbursement suggestions. The reimbursement processing method according to claim 1, wherein before the step of using the product of the incidence rate and a preset utilization rate adjustment coefficient as the utilization rate of the specific drug, the reimbursement processing method further includes step: Determining the adjustment coefficient of the incidence rate according to the disease life cycle of the chronic myeloid leukemia in the city of the same type as the target city in the empirical data and the natural growth rate of the disease; The product of the morbidity adjustment factor and (1+preset additional risk factor incidence rate) is used as the utilization rate adjustment factor. The reimbursement processing method according to claim 1, wherein the risk premium Before the step of multiplying the product of the preset price adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine, the reimbursement processing method further includes the steps of: Obtain the operating cost adjustment factor, tax rate and target profit rate; The preset pricing adjustment factor is calculated according to the following algorithm: The preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate). The reimbursement processing method according to claim 1, wherein the premiums include first-year premiums and non-first-year premiums, and the preset pricing adjustment coefficients include first-year preset pricing adjustment coefficients and non-first-year preset pricing Adjustment factor, before the step of using the product of the risk premium and the preset pricing adjustment factor as the premium corresponding to the reimbursement amount of the special effect medicine, the reimbursement processing method further includes the step of: Analyze the usage data of competitive products in the empirical data to obtain the distribution factor of competitive products; Obtain the operating cost adjustment factor, tax rate and target profit rate; Calculate the preset pricing adjustment factor for the first year according to the following algorithm: The preset pricing adjustment factor for the first year = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate) * competitive product allocation factor; Calculate the non-first-year preset pricing adjustment factor according to the following algorithm: Non-first-year preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate); The step of using the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine includes: Taking the product of the risk premium and the first-year preset pricing adjustment coefficient as the first-year premium of the special-effect medicine corresponding to the reimbursement amount; The product of the risk premium and the non-first-year preset pricing adjustment coefficient is used as the non-first-year premium of the special effect drug corresponding to the reimbursement amount. The reimbursement processing method according to claim 1, wherein the premiums include A insurance premiums and B insurance premiums, and the product of risk premiums and preset pricing adjustment coefficients is used as the special-effect drug and the reimbursement The steps of the premium corresponding to the amount include: Taking the product of the risk premium, the preset pricing adjustment coefficient and the preset A insurance weight as the A insurance premium corresponding to the special effect drug and the reimbursement amount; Taking the product of the risk premium, the preset pricing adjustment coefficient and the preset B insurance weight as the B insurance premium corresponding to the special effect drug and the reimbursement amount; The sum of the A insurance premium and the B insurance premium is set as the premium. The reimbursement processing method according to claim 1, wherein the medical information includes the medical record of the insured person, a bone marrow aspiration pathology report, and a medication record, and the judgment is based on the medical information of the insured person. The steps of whether the insured person suffers from chronic myeloid leukemia and is imatinib-resistant include: Determine whether the condition recorded in the medical record is chronic myeloid leukemia, and if the condition recorded in the medical record is chronic myeloid leukemia, obtain a bone marrow aspiration pathology report of the insured person; According to the pathological report of bone marrow aspiration of the insured person, the actual disease of the insured person is obtained, and it is determined whether the actual disease is chronic myeloid leukemia; If the actual disease is chronic myelogenous leukemia, whether the insured person is an imatinib-resistant patient is determined according to the medication record. The reimbursement processing method according to claim 6, characterized in that the analysis of the insured person's bone marrow aspiration pathology report results in the insured person's actual illness, and determines whether the actual illness The steps for chronic myeloid leukemia include: Determine whether the provider of the bone marrow aspiration pathology report is a hospital below grade three; If the provider of the bone marrow aspiration pathology report is a hospital below grade three, obtain the BCR/ABL fusion gene test result of the insured person, and determine whether the BCR/ABL fusion gene test result meets the preset requirements; If the result of the BCR/ABL fusion gene test meets the preset requirements, it is determined that the actual disease is chronic myeloid leukemia. A reimbursement processing device is used to process the reimbursement of special effects medicine for treating chronic myeloid leukemia, characterized in that the reimbursement processing device includes the steps of: A first acquisition module, the first acquisition module is used to acquire preset reimbursement quota and experience data, the experience data includes the economic, cultural, medical development level of the target city and the total of the cities of the same type as the target city Population and annual incidence of chronic myeloid leukemia; A prediction module, the prediction module is used to analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city according to the analysis result; A first calculation module, the first calculation module is configured to use the product of the morbidity rate and a preset utilization rate adjustment coefficient as the utilization rate of the special effect medicine; A second calculation module, the second calculation module is used to take the product of the reimbursement amount and the utilization rate as the risk premium; A third calculation module, the third calculation module is configured to use the product of the risk premium and a preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect drug; Judgment module, the judgment module is used to obtain the medical information of the insured person, and determine whether the disease suffered by the insured person is chronic myeloid leukemia and imatinib resistance according to the medical information of the insured person Sexual patients An execution module, the execution module is used to obtain a reimbursement amount corresponding to the premium paid by the insured when the insured suffers from a chronic myeloid leukemia and is imatinib-resistant patient , Generate reimbursement suggestions based on the reimbursement amount and the medical information of the insured person. The reimbursement processing device according to claim 8, wherein the reimbursement processing device further comprises: The first analysis module is used to determine the adjustment coefficient of the incidence rate based on the life cycle of the chronic myeloid leukemia and the natural growth rate of the disease in the city of the same type of target city in the empirical data; The fourth calculation module is configured to use the product of the incidence adjustment factor and (1+preset additional risk factor occurrence rate) as the utilization rate adjustment factor. The reimbursement processing device according to claim 8, wherein the reimbursement processing device further comprises: The third acquisition module is used to acquire the adjustment coefficient of operating expenses, the proportion of taxes and fees and the target profit rate; The fifth calculation module is used to calculate the preset pricing adjustment coefficient according to the following algorithm: The preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate). The reimbursement processing device according to claim 8, wherein the premium includes first-year premium and non-first-year premium, and the preset pricing adjustment coefficient includes the first-year preset pricing adjustment coefficient and the non-first-year preset pricing adjustment coefficient The reimbursement processing device also includes: The second analysis module is used to analyze the competitive data usage data in the empirical data to obtain the competitive product allocation coefficient; The fourth acquisition module is used to acquire the adjustment coefficient of operating expenses, the proportion of taxes and fees and the target profit rate; The sixth calculation module is used to calculate the preset price adjustment coefficient for the first year according to the following algorithm: The preset pricing adjustment factor for the first year = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate) * competitive product allocation factor; The seventh calculation module is used to calculate the preset pricing adjustment coefficient for the non-first year according to the following algorithm: Non-first-year preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate); The third calculation module includes: The first calculation unit is used to take the product of the risk premium and the first-year preset pricing adjustment coefficient as the first-year premium corresponding to the reimbursement amount of the special-effect medicine; The second calculation unit is used to take the product of the risk premium and the non-first-year preset pricing adjustment coefficient as the non-first-year premium of the special-effect medicine corresponding to the reimbursement amount. The reimbursement processing device according to claim 8, wherein the premiums include A insurance premiums and B insurance premiums, and the third calculation module includes: The third calculation unit is used to take the product of the risk premium, the preset pricing adjustment coefficient and the preset A insurance weight as the A insurance premium corresponding to the special effect medicine and the reimbursement amount; The fourth calculation unit is used to take the product of the risk premium, the preset pricing adjustment coefficient and the preset B insurance weight as the B insurance premium corresponding to the special effect medicine and the reimbursement amount; The fifth calculation unit is used to set the sum of A insurance premiums and B insurance premiums as premiums. A terminal is characterized in that the terminal includes a processor, a memory, and computer-readable instructions stored on the memory and executable by the processor, wherein the computer-readable instructions are executed by the processor When executed, the following steps are implemented: Obtain preset reimbursement amount and empirical data, the empirical data includes the economic, cultural, medical development level of the target city and the total population of the city of the same type as the target city and the annual incidence of chronic myeloid leukemia; Analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results; Taking the product of the incidence rate and the preset utilization rate adjustment coefficient as the utilization rate of the specific effect drug; Take the product of the reimbursement amount and the utilization rate as the risk premium; Taking the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect drug; Obtain the medical information of the insured person, and determine whether the condition of the insured person is chronic myeloid leukemia and imatinib-resistant patients according to the medical information of the insured person; If the disease suffered by the insured person is chronic myelogenous leukemia and is imatinib-resistant patient, obtain the reimbursement amount corresponding to the premium paid by the insured person, based on the reimbursement amount and the The insured's medical information generates reimbursement suggestions. The terminal according to claim 13, wherein before the step of using the product of the morbidity rate and a preset utilization rate adjustment coefficient as the utilization rate of the specific drug, the reimbursement processing method further includes the step of: Determining the adjustment coefficient of the incidence rate according to the disease life cycle of the chronic myeloid leukemia in the city of the same type as the target city in the empirical data and the natural growth rate of the disease; The product of the morbidity adjustment factor and (1+preset additional risk factor incidence rate) is used as the utilization rate adjustment factor. The terminal according to claim 13, wherein the risk premium Before the step of multiplying the product of the preset price adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine, the reimbursement processing method further includes the steps of: Obtain the operating cost adjustment factor, tax rate and target profit rate; The preset pricing adjustment factor is calculated according to the following algorithm: The preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate). The terminal according to claim 13, wherein the premiums include first-year premiums and non-first-year premiums, and the preset pricing adjustment coefficients include first-year preset pricing adjustment coefficients and non-first-year preset pricing adjustment coefficients Before the step of using the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine, the reimbursement processing method further includes the steps of: Analyze the usage data of competitive products in the empirical data to obtain the distribution factor of competitive products; Obtain the operating cost adjustment factor, tax rate and target profit rate; Calculate the preset pricing adjustment factor for the first year according to the following algorithm: The preset pricing adjustment factor for the first year = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate) * competitive product allocation factor; Calculate the non-first-year preset pricing adjustment factor according to the following algorithm: Non-first-year preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate); The step of using the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine includes: Taking the product of the risk premium and the first-year preset pricing adjustment coefficient as the first-year premium of the special-effect medicine corresponding to the reimbursement amount; The product of the risk premium and the non-first-year preset pricing adjustment coefficient is used as the non-first-year premium of the special effect drug corresponding to the reimbursement amount. The terminal according to claim 13, wherein the premiums include A insurance premiums and B insurance premiums, and the product of the risk premium and the preset pricing adjustment coefficient corresponds to the reimbursement amount of the special effect drug The premium steps include: Taking the product of the risk premium, the preset pricing adjustment coefficient and the preset A insurance weight as the A insurance premium corresponding to the special effect drug and the reimbursement amount; Taking the product of the risk premium, the preset pricing adjustment coefficient and the preset B insurance weight as the B insurance premium corresponding to the special effect drug and the reimbursement amount; The sum of the A insurance premium and the B insurance premium is set as the premium. A computer-readable storage medium, characterized in that computer-readable instructions are stored on the computer-readable storage medium, and when the computer-readable instructions are executed by a processor, the following steps are implemented: Obtain preset reimbursement amount and empirical data, the empirical data includes the economic, cultural, medical development level of the target city and the total population of the city of the same type as the target city and the annual incidence of chronic myeloid leukemia; Analyze the empirical data and predict the incidence of chronic myeloid leukemia in the target city based on the analysis results; Taking the product of the incidence rate and the preset utilization rate adjustment coefficient as the utilization rate of the specific effect drug; Take the product of the reimbursement amount and the utilization rate as the risk premium; Taking the product of the risk premium and the preset pricing adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect drug; Obtain the medical information of the insured person, and determine whether the condition of the insured person is chronic myeloid leukemia and imatinib-resistant patients according to the medical information of the insured person; If the disease suffered by the insured person is chronic myelogenous leukemia and is imatinib-resistant patient, obtain the reimbursement amount corresponding to the premium paid by the insured person, based on the reimbursement amount and the The insured's medical information generates reimbursement suggestions. The computer-readable storage medium according to claim 18, wherein before the step of using the product of the morbidity rate and a preset utilization rate adjustment coefficient as the utilization rate of the specific drug, the reimbursement processing method It also includes steps: Determining the adjustment coefficient of the incidence rate according to the disease life cycle of the chronic myeloid leukemia in the city of the same type as the target city in the empirical data and the natural growth rate of the disease; The product of the morbidity adjustment factor and (1+preset additional risk factor incidence rate) is used as the utilization rate adjustment factor. The computer-readable storage medium of claim 18, wherein the risk premium Before the step of multiplying the product of the preset price adjustment coefficient as the premium corresponding to the reimbursement amount of the special effect medicine, the reimbursement processing method further includes the steps of: Obtain the operating cost adjustment factor, tax rate and target profit rate; The preset pricing adjustment factor is calculated according to the following algorithm: The preset pricing adjustment factor = (1 + operating expense adjustment factor) / (1- tax rate-target profit rate).