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WO2020082807A1 - Procédé et dispositif de contrôle des risques liés aux fonds d'assurance maladie à base d'une analyse de données, serveur et support - Google Patents

Procédé et dispositif de contrôle des risques liés aux fonds d'assurance maladie à base d'une analyse de données, serveur et support Download PDF

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Publication number
WO2020082807A1
WO2020082807A1 PCT/CN2019/095051 CN2019095051W WO2020082807A1 WO 2020082807 A1 WO2020082807 A1 WO 2020082807A1 CN 2019095051 W CN2019095051 W CN 2019095051W WO 2020082807 A1 WO2020082807 A1 WO 2020082807A1
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WIPO (PCT)
Prior art keywords
medical
target user
information
target
medical insurance
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Ceased
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PCT/CN2019/095051
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English (en)
Chinese (zh)
Inventor
周竹凌
汪丽娟
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Ping An Medical and Healthcare Management Co Ltd
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Ping An Medical and Healthcare Management Co Ltd
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Publication of WO2020082807A1 publication Critical patent/WO2020082807A1/fr
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    • G—PHYSICS
    • G06—COMPUTING OR CALCULATING; COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q40/00—Finance; Insurance; Tax strategies; Processing of corporate or income taxes
    • G06Q40/08—Insurance

Definitions

  • the present application relates to the field of computer technology, and in particular to a medical insurance fund risk control method, device, server, and medium based on data analysis.
  • Embodiments of the present application provide a medical insurance fund risk control method, device, server, and medium based on data analysis, which can effectively detect users who have abnormally swiped medical insurance cards to supervise, thereby reducing the loss of medical insurance funds.
  • an embodiment of the present application provides a medical insurance fund risk control method based on data analysis, including:
  • the trajectory information includes location information of using the medical insurance card within a preset time range, and / or within the preset time range Time information for using the medical insurance card;
  • the target medical point included in the active area corresponding to the target user monitors the target user, obtain the medical information of the target user at the target medical point;
  • the diagnosis and treatment information of the target user at the target medical point determine whether the target user's card swiping behavior against the medical insurance card is abnormal;
  • the target user's logo is added to the mark list.
  • an embodiment of the present application provides a medical insurance fund risk control device based on data analysis, including:
  • a determining unit configured to determine the active area corresponding to the target user according to the target user's medical insurance card usage trajectory information; the use trajectory information includes location information of using the medical insurance card within a preset time range, and / or Time information for using the medical insurance card within a preset time range;
  • An obtaining unit configured to obtain the medical information of the target user at the target medical point when the target user is monitored in the target medical point included in the active area corresponding to the target user;
  • the processing unit is configured to determine whether the target user's card swiping behavior for the medical insurance card is abnormal based on the target user's diagnosis and treatment information at the target medical point;
  • the processing unit is further configured to add the identification of the target user to the mark list when it is determined that the target user's swiping behavior against the medical insurance card is abnormal.
  • an embodiment of the present application provides a server, including a processor, an input device, an output device, and a memory, where the processor, input device, output device, and memory are connected to each other, wherein the memory is used to store a computer A program, the computer program includes program instructions, and the processor is configured to call the program instructions to perform the method according to the first aspect.
  • an embodiment of the present application provides a computer-readable storage medium that stores a computer program, where the computer program includes program instructions, which when executed by a processor causes The processor executes the method according to the first aspect.
  • the server can determine the active area corresponding to the target user according to the trajectory information of the target user's medical insurance card, and identify abnormal users based on the diagnosis and treatment information of the target medical point included in the active area by the target user, thereby Effectively detect users who have abnormally swiped medical insurance cards to supervise, thereby reducing the loss of medical insurance funds.
  • FIG. 1 is a schematic flowchart of a medical insurance fund risk control method based on data analysis provided by an embodiment of the present application
  • FIG. 2 is a schematic flowchart of another medical insurance fund risk control method based on data analysis provided by an embodiment of the present application
  • FIG. 3 is a schematic structural diagram of a medical insurance fund risk control device based on data analysis provided by an embodiment of the present application
  • FIG. 4 is a schematic structural diagram of a server provided by an embodiment of the present application.
  • FIG. 1 is a schematic flowchart of a medical insurance fund risk control method based on data analysis provided by an embodiment of the present application.
  • the method can be applied to a server, and the server can be a server or server cluster in the Internet. Specifically, the method may include the following steps:
  • the target user is a suspect of fraudulent insurance determined according to the trajectory information of the medical insurance card.
  • the usage track information may include position information of using the medical insurance card within a preset time range, and / or time information of using the medical insurance card within the preset time range.
  • the preset time range includes, but is not limited to, a time range of nearly one month, half a year, and so on.
  • the server may obtain the medical insurance card usage trajectory information of multiple users according to the target user's medical insurance card usage trajectory information; Information to count the number of times the multiple users use the medical insurance card within a preset time range; the server determines the users who use the medical insurance card more than or equal to the preset number of times from the multiple users; the server uses the medical insurance card more than the number of times The user equal to the preset number of times is regarded as the target user.
  • the multiple users may refer to users recorded in the database. In one embodiment, the multiple users may also be users who have historically recorded fraudulent behaviors in the database.
  • the multiple users include user A, user B, and user C.
  • user A's medical insurance card usage trajectory information it can be determined that user A has used the medical insurance card 5 times in the past month, and user B has used it in the last month
  • the number of medical insurance cards is 25, and the number of times that user C has used the medical insurance card in the past month is one.
  • the server can determine from these three users that user B has used the medical insurance card more than 20 times, and regard user B as the target user .
  • the usage trajectory information includes location information for using the medical insurance card within a preset time range and time information for using the medical insurance card within the preset time range, and the location information for using the medical insurance card includes using the medical insurance The location information of the medical point of the card; the server determines the active area corresponding to the target user according to the trajectory information of the target user's medical insurance card, which may include: the server determines from the time information of using the medical insurance card within the preset time range The time information of using the medical insurance card closest to the system time; the server determines the location information of the medical point corresponding to the time information of using the medical insurance card closest to the system time; the server will determine the location of the medical point using the medical insurance card The area corresponding to the location information serves as the active area corresponding to the target user.
  • the area may be divided according to various forms.
  • the area may be within a preset position range centered on the medical point corresponding to the time information using the medical insurance card that is closest to the system time, or may be The district, state, city, province, etc. to which the medical point corresponding to the time information using the medical insurance card closest to the system time belongs.
  • the server determines that the time information of using the medical insurance card closest to the system time is July 12, 2018; the server determines the use of the medical insurance card closest to the system time.
  • the location information of the medical point corresponding to the time information of the medical insurance card is hospital A; the server will determine the area corresponding to hospital A as the active area corresponding to the target user.
  • the server determines the active area corresponding to the target user according to the target user's medical insurance card usage trajectory information, which may include: the server according to the location information of the medical insurance card used within a preset time range, and Use the time information of the medical insurance card within a set time range to determine the number of times the medical insurance card is used in each area in the area corresponding to the location information of the target user using the medical insurance card within the preset time range; In the area corresponding to the location information of using the medical insurance card within the time range, the area with the most use of the medical insurance card is determined; the server uses the area with the most use as the active area of the target user.
  • the target medical point refers to a medical point for monitoring whether a target user exists.
  • the server may call the camera device corresponding to the target medical point included in the active area corresponding to the target user to monitor whether the target user exists.
  • the server may obtain information of at least one medical point included in the active area corresponding to the target user; the information of the at least one medical point includes the medical insurance reimbursement ratio of the at least one medical point; the server From the at least one medical point, the medical point with the largest medical insurance reimbursement ratio is determined; the server takes the medical point with the largest medical insurance reimbursement ratio as the target medical point.
  • the active area corresponding to the target user is area A
  • at least one medical point included in area A is medical point 1, medical point 2, medical point 3, wherein the medical insurance reimbursement ratio of medical point 1 is 30%, medical point 2 Of medical insurance reimbursement rate is 40%, medical point 3 medical insurance reimbursement rate is 60%
  • the server can determine the medical point 3 medical insurance reimbursement rate is the largest, and medical point 3 as the target medical point.
  • the above medical insurance reimbursement ratio may be determined according to the target user's medical insurance card type.
  • the medical insurance reimbursement ratio may refer to the medical insurance reimbursement ratio corresponding to the rural resident medical insurance card.
  • the type of the medical insurance card can be divided in various forms, including but not limited to rural residents' medical insurance cards, urban residents' medical insurance cards, urban employees' medical insurance cards and other types of medical insurance cards.
  • the server may preset the correspondence between different areas and the information of medical points included in each area in the different area, so that the server may For the correspondence relationship of the information of medical points, the information of at least one medical point included in the active area corresponding to the target user is acquired.
  • the server in addition to the medical point with the largest reimbursement rate as the target medical point, can also determine the medical center that uses the medical insurance card the most frequently by the target user in the area identified as the most used medical insurance card from the foregoing Point, and the medical point identified by the target user from the area with the highest number of medical insurance card use times as the target medical point.
  • the server may send a diagnosis confirmation request to the device corresponding to the target medical point; the server receives the corresponding The confirmation result returned by the device for the diagnosis confirmation request; when the confirmation result indicates that the diagnosis information of the target user at the target medical point is empty, the server adds the identification of the target user to the mark list.
  • the device corresponding to the target medical point may be a smart terminal such as a desktop computer, a notebook computer, or a tablet computer corresponding to the target medical point.
  • the mark list includes identifications of at least one user, and each user in the at least one user is a determined user whose card swiping behavior is abnormal for each corresponding medical insurance card.
  • the device corresponding to the target medical point may, when receiving the diagnosis confirmation request sent by the server, query whether the target user's diagnosis and treatment information at the target medical point is stored locally;
  • the diagnosis and treatment information of the target user at the target medical point, and the confirmation result returned for the diagnosis confirmation request indicates that the diagnosis and treatment information of the target user at the target medical point is empty; when it is found that the target user is stored in the target medical point this time
  • the diagnosis and treatment information of the point, the confirmation result returned for the diagnosis and treatment confirmation request includes the diagnosis and treatment information of the target user at the target medical point.
  • the confirmation result includes the diagnosis and treatment information of the target user at the target medical point
  • obtaining the diagnosis and treatment information of the target user at the target medical point may include: the server acquiring the target user included in the confirmation result Diagnosis and treatment information at the target medical point.
  • S103 According to the diagnosis and treatment information of the target user at the target medical point, determine whether the card swiping behavior of the target user for the medical insurance card is abnormal.
  • the server may determine whether the target user's card swiping behavior for the medical insurance card is abnormal according to the target user's diagnosis and treatment information at the target medical point.
  • the diagnosis and treatment information may include the diagnosis and treatment items of the diagnosis and treatment, and may also include the diagnosis and treatment duration corresponding to the diagnosis and treatment items of the diagnosis and treatment.
  • the diagnosis and treatment information includes diagnosis and treatment items
  • the server determines whether the target user's swiping behavior for the medical insurance card is abnormal based on the diagnosis and treatment information of the target user at the target medical point, which may include: the server according to the target The diagnosis and treatment items of the user's diagnosis and treatment at the target medical point determine the first diagnosis and treatment trajectory information of the target user at the target medical point; the server acquires the second diagnosis and treatment trajectory information of the target user at the target medical point collected by the camera device; the server determines Whether the first diagnosis and treatment trajectory information is the same as the second diagnosis and treatment trajectory information; when the first diagnosis and treatment trajectory information and the second diagnosis and treatment trajectory information are not the same, the server determines that the target user's card swiping behavior against the medical insurance card is abnormal.
  • the server determines whether the target user's card swiping behavior against the medical insurance card is abnormal.
  • the first diagnosis and treatment trajectory information may include each diagnosis and treatment item in the diagnosis and treatment items of the diagnosis and treatment, sorted according to the order of the diagnosis and treatment time, and each sorted diagnosis and treatment item obtained.
  • the second diagnosis and treatment trajectory information may include the diagnosis and treatment items collected by the camera device for the diagnosis and treatment of the target user at the target medical point, and sorted according to the order of diagnosis and treatment time, and the obtained sorted diagnosis and treatment items.
  • the server determines whether the first diagnosis and treatment trajectory information is the same as the second diagnosis and treatment trajectory information, in addition to determining whether the diagnosis and treatment items in the first trajectory information and the second diagnosis and treatment items are the same, it is also necessary to determine Whether the order of each diagnosis and treatment item in the diagnosis and treatment items in the first track information is the same as the order of each diagnosis and treatment item in the diagnosis and treatment items in the second track information; when determining the diagnosis and treatment items in the first track information and the diagnosis and treatment items in the second track information It is the same, and when the order of the diagnosis items in the diagnosis items in the first trajectory information is the same as the order of the diagnosis items in the diagnosis items in the second trajectory information, it is determined that the first diagnosis trajectory information and the second diagnosis trajectory information are the same.
  • the first trajectory information may further include the diagnosis and treatment areas corresponding to each diagnosis and treatment item in the diagnosis and treatment items of the diagnosis and treatment, according to the order of diagnosis and treatment time, the obtained sorted diagnosis and treatment areas, the second track
  • the information may also include the areas corresponding to the diagnosis and treatment items of the target user's diagnosis and treatment at the target medical point collected by the camera device, sorted according to the time of diagnosis and treatment time, and the corresponding areas of the sorted diagnosis and treatment items obtained.
  • the server determines whether the first diagnosis trajectory information is the same as the second diagnosis trajectory information, in addition to determining the diagnosis area corresponding to the diagnosis item in the first trajectory information and the diagnosis treatment corresponding to the diagnosis item in the second trajectory information If the areas are the same, it is also necessary to determine whether the order of the diagnosis area corresponding to each diagnosis item in the first trajectory information is the same as the order of the diagnosis area corresponding to each diagnosis item in the second trajectory information;
  • the diagnosis area corresponding to the diagnosis item in the first track information is the same as the diagnosis area corresponding to the diagnosis item in the second track information, and the order of the diagnosis area corresponding to each diagnosis item in the diagnosis item in the first track information is the same as the second track
  • the order of the diagnosis and treatment regions corresponding to each diagnosis and treatment item in the diagnosis and treatment items in the information is the same, it is determined that the first diagnosis and treatment trajectory information and the second diagnosis and treatment trajectory information are the same.
  • the server may acquire the diagnosis information of the target user at the target medical point from the device corresponding to the target medical point, so that the server determines the target user based on the diagnosis and treatment items of the target user at the target medical point Trajectory information of the first diagnosis and treatment of the target medical point.
  • the diagnosis and treatment information includes the diagnosis and treatment duration corresponding to the diagnosis and treatment item of the diagnosis and treatment
  • the server determines whether the target user's swiping behavior for the medical insurance card is abnormal based on the diagnosis and treatment information of the target user at the target medical point
  • the method includes: the server determines whether the duration of the diagnosis and treatment corresponding to the diagnosis and treatment item of the target user at the target medical point matches the preset diagnosis and treatment duration for the diagnosis and treatment item of the diagnosis and treatment, when the target user targets the diagnosis and treatment at the target medical point
  • the server determines that the target user's card swiping behavior against the medical insurance card is abnormal.
  • the duration of the diagnosis and treatment corresponding to the diagnosis and treatment item for the diagnosis and treatment may be the length of stay of the diagnosis and treatment area corresponding to the diagnosis and treatment item detected by the camera device.
  • the server may add the target user's logo to the mark list.
  • the server may also send an alarm message to the device corresponding to the target medical point when it is determined that the target user's card-swapping behavior is abnormal for the medical insurance card to remind the medical personnel of the target medical point.
  • the server can determine the active area corresponding to the target user according to the trajectory information of the target user's medical insurance card; when the target medical point included in the active area corresponding to the target user monitors the target As a user, the server can obtain the diagnosis and treatment information of the target user at the target medical point, and based on the diagnosis and treatment information of the target user at the target medical point, determine whether the card swiping behavior of the target user against the medical insurance card is abnormal; when the target is determined When the user's card swiping behavior is abnormal for the medical insurance card, the server adds the target user's identification to the mark list, so as to effectively detect the user for the medical card's abnormal swiping behavior to supervise, thereby reducing the loss of the medical insurance fund.
  • FIG. 2 is a schematic flowchart of a medical insurance fund risk control method based on data analysis provided by an embodiment of the present application. Specifically, the method may include the following steps:
  • the target user is a suspect of fraudulent insurance determined according to the trajectory information of the medical insurance card.
  • the usage track information may include position information of using the medical insurance card within a preset time range, and / or time information of using the medical insurance card within the preset time range.
  • the preset time range includes, but is not limited to, a time range of nearly one month, half a year, and so on.
  • step S201 reference may be made to step S101 in the embodiment of FIG. 1, and embodiments of the present application will not repeat them here.
  • S202 According to the time information of using the medical insurance card within a preset time range, count the frequency of the target user's card swiping for the medical insurance card in preset multiple time periods.
  • the preset multiple time periods may be divided according to various forms, and the embodiment of the present application does not limit the preset multiple time periods.
  • the preset multiple time periods can be divided according to working days and rest days: Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, and weekend, or can be divided according to morning, noon, and evening , Can also be divided by month, such as January, February, March and other months.
  • the unit of the frequency of card swiping may be calculated in days, such as times / day, or may be calculated according to weeks, such as times / weeks, or may be calculated according to months, such as times / months.
  • the units are not limited and can be set according to actual needs.
  • S203 Determine, from the preset multiple time periods, a time period in which the card swiping frequency for the medical insurance card is greater than or equal to the preset frequency.
  • a key monitoring time period can be effectively determined for monitoring.
  • the preset multiple time periods include morning, afternoon, and evening.
  • the preset time range is nearly a month.
  • the server can count the frequency of the target user's card swiping against the medical insurance card in the morning of the last month is 1 / Monthly, the frequency of swiping against the medical insurance card in the afternoon of the past month is 2 times / month, and the frequency of swiping against the medical insurance card in the evening of the last month is 23 times / month.
  • the server can select from these three time periods It is determined that the time period for the frequency of card swiping is greater than or equal to 20 times / month is evening.
  • the server may send a monitoring instruction to the camera device corresponding to the target medical point, so that when the camera device corresponding to the target medical point receives the monitoring instruction, the monitoring function may be activated to The target medical point included in the active area monitors whether the target user exists.
  • the server may send a monitoring instruction to the device corresponding to the target medical point to instruct the device corresponding to the target medical point to activate the monitoring function of the camera device corresponding to the target medical point, so that the camera The target medical point included in the active area corresponding to the user monitors whether the target user exists.
  • steps S205-S207 reference may be made to steps S102-S104 in the embodiment of FIG. 1, which will not be repeated in the embodiments of the present application.
  • the server may determine the active area corresponding to the target user according to the trajectory information of the target user's medical insurance card, and the frequency of card swiping for the medical insurance card within the preset time range is greater than the preset In the time period of the frequency, the camera is called to monitor whether the target user exists in the target medical point included in the active area corresponding to the target user; when the target medical point included in the active area corresponding to the target user monitors the target user, the server The target user's diagnosis and treatment information at the target medical point can be obtained, and according to the target user's diagnosis and treatment information at the target medical point, whether the target user's card swiping behavior against the medical insurance card is abnormal is determined; when the target user is determined to target the medical insurance When the card's card swiping behavior is abnormal, the server adds the target user's logo to the mark list, so as to effectively detect the user who has abnormally swiped the medical insurance card to supervise, thereby reducing the loss of
  • FIG. 3 is a schematic structural diagram of a medical insurance fund risk control device based on data analysis provided by an embodiment of the present application.
  • the device can be applied to a server.
  • the device may include:
  • the determining unit 11 is configured to determine an active area corresponding to the target user according to the target user's medical insurance card usage trajectory information; the use trajectory information includes location information of using the medical insurance card within a preset time range, and / or The time information for using the medical insurance card within the preset time range;
  • the obtaining unit 12 is configured to obtain the diagnosis and treatment information of the target user at the target medical point when the target user is monitored in the target medical point included in the active area corresponding to the target user;
  • the processing unit 13 is configured to determine whether the target user's card swiping behavior for the medical insurance card is abnormal based on the target user's diagnosis and treatment information at the target medical point;
  • the processing unit 13 is further configured to add the identification of the target user to the mark list when it is determined that the target user's swiping behavior against the medical insurance card is abnormal.
  • the acquiring unit 12 is further configured to acquire the medical insurance card usage of multiple users before the determining unit 11 determines the active area corresponding to the target user according to the trajectory information of the medical insurance card usage of the target user Track information.
  • the processing unit 13 is further configured to count the number of times the medical insurance cards are used by the multiple users within a preset time range based on the track information of the medical insurance cards used by the multiple users; Among the plurality of users, a user who has used the medical insurance card more than or equal to a preset number of times is determined; and the user who uses the medical insurance card more than or equal to the preset number of times is regarded as the target user.
  • the usage trajectory information includes location information for using the medical insurance card within a preset time range and time information for using the medical insurance card within the preset time range.
  • the location information of the card includes location information of medical points using the medical insurance card.
  • the determining unit 11 is specifically configured to determine the time information for using the medical insurance card closest to the system time from the time information for using the medical insurance card within the preset time range Determine the location information of the medical point corresponding to the time information of the medical insurance card closest to the system time; the area corresponding to the determined location information of the medical point using the medical insurance card as the target The active area corresponding to the user.
  • the diagnosis and treatment information includes diagnosis and treatment items.
  • the processing unit 13 is specifically configured to determine the first diagnosis and treatment trajectory information of the target user at the target medical point according to the diagnosis and treatment items of the target user at the target medical point Obtain the second diagnosis trajectory information of the target user at the target medical point collected by the camera device; determine whether the first diagnosis trajectory information is the same as the second diagnosis trajectory information; when the first diagnosis trajectory information When it is different from the second diagnosis and treatment trajectory information, it is determined that the target user's card swiping behavior against the medical insurance card is abnormal.
  • the acquiring unit 12 is further configured to acquire the target user at the target medical point when the target user is monitored in the target medical point included in the area where the target user is located Before the diagnosis and treatment information, obtain the information of at least one medical point included in the active area corresponding to the target user; the information of the at least one medical point includes the medical insurance reimbursement ratio of the at least one medical point.
  • the determining unit 11 is further configured to determine the medical point with the largest medical insurance reimbursement rate from the at least one medical point, and use the medical point with the largest medical insurance reimbursement rate as the target medical treatment point.
  • the usage track information includes time information for using the medical insurance card within the preset time range.
  • the processing unit 13 is further configured to obtain the target user's presence through the obtaining unit 12 when the target medical point included in the active area corresponding to the target user monitors the target user Before the diagnosis and treatment information of the target medical point, according to the time information of using the medical insurance card within the preset time range, count the frequency of the target user's card swiping against the medical insurance card in preset multiple time periods; In the preset multiple time periods, a time period in which the card swiping frequency for the medical insurance card is greater than or equal to a preset frequency is determined; in a time period in which the card swiping frequency is greater than the preset frequency, the camera is called in the The target medical point included in the active area corresponding to the target user monitors whether the target user exists.
  • the communication unit 14 is configured to send a diagnosis confirmation request to the target medical point when the target medical point included in the active area corresponding to the target user monitors the target user Device; receiving the confirmation result returned by the device corresponding to the target medical point for the diagnosis confirmation request.
  • processing unit 13 is further configured to add the identification of the target user to the mark list when the confirmation result indicates that the diagnosis information of the target user at the target medical point is empty in.
  • the server can determine the active area corresponding to the target user according to the trajectory information of the target user's medical insurance card; when the target medical point included in the active area corresponding to the target user monitors the target As a user, the server can obtain the diagnosis and treatment information of the target user at the target medical point, and based on the diagnosis and treatment information of the target user at the target medical point, determine whether the card swiping behavior of the target user against the medical insurance card is abnormal; when the target is determined When the user's card swiping behavior is abnormal for the medical insurance card, the server adds the target user's identification to the mark list, so as to effectively detect the user for the medical card's abnormal swiping behavior to supervise, thereby reducing the loss of the medical insurance fund.
  • FIG. 4 is a schematic structural diagram of a server according to an embodiment of the present application.
  • the server described in this embodiment may include one or more processors 100, one or more input devices 200, one or more output devices 300, and a memory 400.
  • the processor 100, the input device 200, the output device 300, and the memory 400 may be connected through a bus.
  • the input device 200 and the output device 300 may be standard wired or wireless communication interfaces.
  • the processor 100 may be a central processing module (Central Processing Unit, CPU), the processor may also be other general-purpose processors, digital signal processors (Digital Signal Processor, DSP), application specific integrated circuits (Application Specific Integrated Circuit, ASIC) 2. Ready-made programmable gate array (Field-Programmable Gate Array, FPGA) or other programmable logic devices, discrete gate or transistor logic devices, discrete hardware components, etc.
  • the general-purpose processor may be a microprocessor or the processor may be any conventional processor or the like.
  • the memory 400 may be a high-speed RAM memory or a non-volatile memory (non-volatile memory), such as a disk memory.
  • the memory 400 is used to store a set of program codes, and the input device 200, the output device 300, and the processor 100 can call the program codes stored in the memory 400. specifically:
  • the processor 100 is configured to determine an active area corresponding to the target user according to the target user's medical insurance card usage trajectory information; the use trajectory information includes location information of using the medical insurance card within a preset time range, and / or Use the time information of the medical insurance card within the preset time range; when the target medical point included in the active area corresponding to the target user monitors the target user, obtain the target user ’s Diagnosis and treatment information; based on the diagnosis and treatment information of the target user at the target medical point, determine whether the target user's swipe behavior against the medical insurance card is abnormal; when it is determined that the target user's swipe behavior against the medical insurance card is abnormal To add the target user's logo to the mark list.
  • the processor 100 is further configured to acquire the medical insurance card usage trajectory information of multiple users before determining the active area corresponding to the target user according to the medical insurance card usage trajectory information of the target user; according to the multiple users Of medical insurance card usage trajectory information, count the number of times that the multiple users use the medical insurance card within a preset time range; from the multiple users, determine the users who use the medical insurance card more than or equal to the preset number of times; The user who uses the medical insurance card more than or equal to the preset number as the target user.
  • the usage track information includes location information for using the medical insurance card within a preset time range and time information for using the medical insurance card within the preset time range, and the location information for using the medical insurance card includes use Location information of medical points of the medical insurance card.
  • the processor 100 determines the active area corresponding to the target user according to the trajectory information of the target user's medical insurance card, specifically determining the distance from the time information of using the medical insurance card within the preset time range The time information of using the medical insurance card with the latest system time; determining the position information of the medical point corresponding to the time information of using the medical insurance card with the closest system time; the determined medical treatment with the medical insurance card will be determined
  • the area corresponding to the position information of the point serves as the active area corresponding to the target user.
  • the diagnosis and treatment information includes diagnosis and treatment items.
  • the processor 100 determines whether the target user's swiping behavior for the medical insurance card is abnormal based on the target user's diagnosis and treatment information at the target medical point, specifically based on the target user's
  • the diagnosis and treatment items of the point diagnosis and treatment determine the first diagnosis and treatment trajectory information of the target user at the target medical point; obtain the second diagnosis and treatment trajectory information of the target user collected by the camera device at the target medical point; and determine the first Whether the first diagnosis and treatment trajectory information is the same as the second diagnosis and treatment trajectory information; when the first diagnosis and treatment trajectory information and the second diagnosis and treatment trajectory information are not the same, it is determined that the target user's swiping behavior against the medical insurance card is abnormal.
  • the processor 100 is further configured to, when the target medical point included in the area where the target user is located monitors the target user, acquire the target user's diagnosis and treatment information at the target medical point before acquiring Information of at least one medical point included in the active area corresponding to the target user; information of the at least one medical point includes a medical insurance reimbursement ratio of the at least one medical point; from the at least one medical point, a medical insurance reimbursement is determined The medical point with the largest proportion; the medical point with the largest proportion of the medical insurance reimbursement as the target medical point.
  • the usage track information includes time information for using the medical insurance card within the preset time range.
  • the processor 100 is further configured to, when the target medical point included in the active area corresponding to the target user monitors the target user, obtain the target user's medical information before the target medical point, According to the time information of using the medical insurance card within the preset time range, count the frequency of the target user's card swiping for the medical insurance card in preset multiple time periods; from the preset multiple time periods , Determine the time period when the card swiping frequency for the medical insurance card is greater than or equal to the preset frequency; during the time period when the card swiping frequency is greater than the preset frequency, call the camera to include the target included in the active area corresponding to the target user The medical point monitors whether the target user exists.
  • the processor 100 is further configured to, when the target medical point included in the active area corresponding to the target user monitors the target user, send a diagnosis confirmation request to the corresponding medical point through the output device 300 Device; receiving the confirmation result returned by the device corresponding to the target medical point for the diagnosis confirmation request through the input device 200; when the confirmation result indicates that the diagnosis information of the target user at the target medical point is empty, the The target user's logo is added to the tag list.
  • the processor 100, the input device 200, and the output device 300 described in the embodiments of the present application may execute the implementation modes described in the embodiment of FIG. 1 and the embodiment of FIG. 2, and may also perform The implementation method will not be repeated here.
  • the functional modules in the embodiments of the present application may be integrated into one processing module, or each module may exist alone physically, or two or more modules may be integrated into one module.
  • the above integrated modules can be implemented in the form of sampling hardware or in the form of sampling software function modules.
  • the readable storage medium may be a magnetic disk, an optical disk, a read-only memory (Read-Only Memory, ROM) or a random storage memory (Random Access Memory, RAM), etc.

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Abstract

Des modes de réalisation de la présente invention concernent un procédé et un dispositif de contrôle des risques liés aux fonds d'assurance maladie à base d'une analyse de données, un serveur et un support. Le procédé consiste : à déterminer une zone active correspondant à un utilisateur cible en fonction des informations de trajectoire d'une carte d'assurance maladie de l'utilisateur cible ; à obtenir, lorsqu'un site médical cible compris dans la zone active correspondant à l'utilisateur cible surveille l'utilisateur cible, des informations médicales de l'utilisateur cible au niveau du site médical cible ; à déterminer, en fonction des informations médicales de l'utilisateur cible au niveau du site médical cible, si un comportement de glissement de carte de l'utilisateur cible pour la carte d'assurance maladie est anormal ; et à ajouter, lorsqu'il est déterminé qu'un comportement de glissement de carte de l'utilisateur cible pour la carte d'assurance maladie est anormal, un identifiant de l'utilisateur cible dans une liste marquée. La présente invention permet de détecter efficacement le comportement anormal de glissement de carte de l'utilisateur pour la carte d'assurance maladie dans le but de la supervision, ce qui permet de réduire la perte au niveau des fonds d'assurance maladie.
PCT/CN2019/095051 2018-10-27 2019-07-08 Procédé et dispositif de contrôle des risques liés aux fonds d'assurance maladie à base d'une analyse de données, serveur et support Ceased WO2020082807A1 (fr)

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