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WO2020119120A1 - Procédé et dispositif d'identification d'achat anormal de médicament, terminal et support de stockage lisible par ordinateur - Google Patents

Procédé et dispositif d'identification d'achat anormal de médicament, terminal et support de stockage lisible par ordinateur Download PDF

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Publication number
WO2020119120A1
WO2020119120A1 PCT/CN2019/096079 CN2019096079W WO2020119120A1 WO 2020119120 A1 WO2020119120 A1 WO 2020119120A1 CN 2019096079 W CN2019096079 W CN 2019096079W WO 2020119120 A1 WO2020119120 A1 WO 2020119120A1
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WO
WIPO (PCT)
Prior art keywords
drug purchase
drug
expenditure
purchase
abnormal
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Ceased
Application number
PCT/CN2019/096079
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English (en)
Chinese (zh)
Inventor
陈明东
黄越
胥畅
符珺
管音
陆江楠
Current Assignee (The listed assignees may be inaccurate. Google has not performed a legal analysis and makes no representation or warranty as to the accuracy of the list.)
Ping An Medical and Healthcare Management Co Ltd
Original Assignee
Ping An Medical and Healthcare Management Co Ltd
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Ping An Medical and Healthcare Management Co Ltd filed Critical Ping An Medical and Healthcare Management Co Ltd
Publication of WO2020119120A1 publication Critical patent/WO2020119120A1/fr
Anticipated expiration legal-status Critical
Ceased legal-status Critical Current

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Classifications

    • 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
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H20/00—ICT specially adapted for therapies or health-improving plans, e.g. for handling prescriptions, for steering therapy or for monitoring patient compliance
    • G16H20/10—ICT specially adapted for therapies or health-improving plans, e.g. for handling prescriptions, for steering therapy or for monitoring patient compliance relating to drugs or medications, e.g. for ensuring correct administration to patients

Definitions

  • This application relates to the field of medical insurance, and in particular to a method, device, terminal, and computer-readable storage medium for identifying abnormal drug purchases.
  • the main purpose of the present application is to provide a method, device, terminal, computer-readable storage medium and computer-readable storage medium for identifying abnormal drug purchases, aiming to identify abnormal drug purchase behaviors for surprise drug purchases.
  • this application provides a method for identifying abnormal drug purchases, including the steps of:
  • the medical insurance account When there is a segment of drug purchase expenditure greater than a preset threshold, the medical insurance account is marked as an object of abnormal drug purchase.
  • the step of obtaining segmented drug purchase expenditures corresponding to multiple consecutive time periods of the insured includes:
  • the drug purchase expenditure corresponding to each time period is obtained.
  • the method for identifying abnormal drug purchase further includes the step of:
  • the method for identifying abnormal drug purchase further includes the step of:
  • the average value of the remaining multiple drug purchase expenditures is calculated, and the preset multiple of the average value is set as the preset threshold, where the preset multiple is greater than 1.
  • the method for identifying abnormal drug purchases further includes the steps of:
  • the medical insurance account is marked as an abnormal drug purchase target.
  • the method for identifying abnormal drug purchases further includes the steps of:
  • the medicine in the drug purchase record in the time period corresponding to the maximum value is related to the illness in the medical record
  • the drug purchase record in the time period corresponding to the maximum value is calculated in the medical record
  • the ratio of the cost of the medicine related to the above condition to the maximum value gives the relevant ratio
  • the medical insurance account is marked as an object of abnormal drug purchase.
  • the method of identifying the abnormal drug purchase further includes the step of:
  • This application also provides an identification device for abnormal drug purchases, including:
  • An obtaining module is used to obtain the drug purchase expenditure corresponding to multiple consecutive time periods of the insured person when the insured person swipes the card to settle the medical bill;
  • a judging module the judging module is used to judge whether each of the drug purchase expenditures is greater than a preset threshold
  • a marking module the marking module is used to mark the medical insurance account as an object of abnormal drug purchase when there is a segment of drug purchase expenditure greater than a preset threshold.
  • the present application also provides a terminal 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 When executed, the steps of the method for identifying abnormal drug purchase as described in any of the above are realized.
  • the present application also provides a computer-readable storage medium having computer-readable instructions stored on the computer-readable storage medium, where the computer-readable instructions are executed by a processor to implement the client as described in any one of the above The steps of the method for identifying abnormal drug purchases.
  • the segmented drug purchase expenditure corresponding to multiple consecutive time periods of the insured obtain the segmented drug purchase expenditure corresponding to multiple consecutive time periods of the insured; determine whether each of the segmented drug purchase expenditure is greater than a preset threshold; when there is a segmented drug purchase expenditure greater than the preset threshold , Mark the medical insurance account as the object of abnormal drug purchase, determine whether the insured person has abnormal drug purchase behavior of surprise drug purchase by judging whether the drug purchase expenditure is greater than the preset threshold, and the drug purchase expenditure in the existing segment is greater than the preset threshold
  • the medical insurance account of the insured person is marked as an abnormal drug purchase object, and the medical insurance management unit can timely identify the abnormal drug purchase behavior of the abnormal drug purchase object by the abnormal drug purchase object through the abnormal drug purchase identification method of the embodiment of the present application and take Corresponding measures.
  • FIG. 1 is a schematic diagram of a hardware structure of a terminal involved in a solution of an embodiment of this application;
  • FIG. 2 is a schematic flowchart of a first embodiment of a method for identifying abnormal drug purchases in this application;
  • FIG. 3 is a schematic flowchart of a second embodiment of a method for identifying abnormal drug purchases in this application
  • FIG. 4 is a schematic flowchart of a third embodiment of a method for identifying abnormal drug purchases in the application
  • FIG. 5 is a schematic flowchart of a fourth embodiment of a method for identifying abnormal drug purchases in this application.
  • the method for identifying abnormal drug purchases according to the embodiments of the present application is mainly applied to a terminal, and the terminal may be a terminal with display and processing functions such as a PC, a portable computer, and a mobile terminal.
  • FIG. 1 is a schematic structural diagram of a terminal involved in a solution according to an embodiment of this 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.
  • 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.
  • 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.
  • 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.
  • the network communication module is mainly used to connect to a 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 following operations:
  • the medical insurance account When there is a segment of drug purchase expenditure greater than a preset threshold, the medical insurance account is marked as an object of abnormal drug purchase.
  • the step of obtaining the segmented drug purchase expenditures corresponding to multiple consecutive time periods of the insured includes:
  • the drug purchase expenditure corresponding to each time period is obtained.
  • the processor 1001 may call computer-readable instructions stored in the memory 1005 and perform the following operations:
  • the processor 1001 may store the computer-readable instructions stored in the computer-readable instructions and perform the following operations:
  • the average value of the remaining multiple drug purchase expenditures is calculated, and the preset multiple of the average value is set as the preset threshold, where the preset multiple is greater than 1.
  • processor 1001 can call the computer-readable instructions stored in the memory 1005 and perform the following operations:
  • the medical insurance account is marked as an abnormal drug purchase target.
  • processor 1001 can call the computer-readable instructions stored in the memory 1005 and perform the following operations:
  • the cost of the drug in the drug purchase record in the time period corresponding to the maximum value in relation to the illness in the medical record is calculated The ratio of the maximum value to the relevant ratio;
  • the medical insurance account is marked as the object of abnormal drug purchase.
  • the processor 1001 may call the computer-readable instructions stored in the memory 1005 and perform the following operations:
  • This application provides a method for identifying abnormally purchased drugs.
  • the method for identifying abnormal drug purchases includes the following steps:
  • the method for identifying abnormal drug purchases in the embodiment of the present application may be executed by a terminal, and the terminal can perform data communication with a server, and the server is connected to management systems of multiple medical institutions.
  • the drug purchase expenditures corresponding to multiple consecutive time periods refer to the drug purchase expenditures within each time period among multiple continuous time periods.
  • the terminal first obtains the personal information of the insured person, and then the terminal obtains the insured person's personal information from the management system of each medical institution through the server according to the personal information of the insured person In multiple consecutive time periods, the drug purchase expenditure in each time period. Specifically, first obtain the drug purchase records of the insured person in multiple consecutive time periods from the management system of each medical institution; then according to the statistics of the drug purchase records in each time period, obtain the drug purchase expenditure corresponding to each time period .
  • S102 Compare the drug purchase expenditure of each segment with a preset threshold, and determine whether there is a segment drug purchase expenditure greater than the preset threshold;
  • segment drug purchase expenditures greater than the preset threshold it is determined that segment drug purchase expenditures are greater than the preset threshold, and when each segment drug purchase expenditure is less than or equal to the preset threshold, it is determined that there is no segment drug purchase expenditure Greater than the preset threshold.
  • the preset threshold may be set before step S102.
  • the sum of the drug purchase expenditures in multiple time periods can be calculated first to obtain the total drug purchase expenditure, and the product of the total drug purchase expenditure and the preset coefficient is set as the preset threshold, where the preset coefficient is greater than 0 and less than 1. For example, you can set the duration of each time period to 1 month, a total of 12 time periods, 12 time periods are 12 consecutive months within a year, the preset coefficient is 0.9, first obtain the monthly period within a year For drug purchase expenditures, the monthly drug purchase expenditures of each month within a year are summed to obtain the total drug purchase expenditures, and then the total drug purchase expenditures are multiplied by 0.9 to obtain the preset threshold.
  • each time period For example, you can set the duration of each time period to 1 month, a total of 12 time periods, 12 time periods are 12 consecutive months within a year, the preset coefficient is 2, compare the size of drug purchase expenditure in 12 periods Relationship, get the largest amount of drug purchase expenditure, after removing the largest amount of drug purchase expenditure, calculate the average of the remaining 11 drug purchase expenditures, double the average of the remaining 11 drug purchase expenditures As a preset threshold.
  • the medical insurance account When there is a segment of drug purchase expenditure greater than a preset threshold, the medical insurance account is marked as an object of abnormal drug purchase. When there is a period of drug purchase expenditure greater than the preset threshold, it means that there is at least one period of abnormal drug purchase behavior that surprises the purchase of drugs.
  • the medical insurance account of the insured is marked as an object of abnormal drug purchase to facilitate the medical insurance management unit’s
  • the staff identified the abnormal drug purchase behavior of the insured in a surprise purchase.
  • the medical insurance account when used to settle the drug purchase bill, it refers to the situation where the medical insurance needs to reimburse part of the cost of the drug purchase bill, and does not include the case where the insured person uses the personal account balance in the medical insurance account to settle the drug purchase bill. That is to say, if the insured person uses the personal account balance in the medical insurance account to settle the drug purchase bill, there is no need to perform the steps of the method for identifying the abnormal drug purchase.
  • the above-mentioned multiple time periods refer to a continuous multiple time period starting from the time point when the insured person swipes and settles the card as a starting point, and before the time point when the credit card is settled.
  • the medical insurance account of the insured person is marked as an abnormal drug purchase object, and the medical insurance management unit can timely identify the abnormal drug purchase behavior of the abnormal drug purchase object through the abnormal drug purchase identification method of the embodiment of the present application. Take corresponding measures.
  • the method for identifying abnormal drug purchases further includes steps:
  • the maximum value among multiple segmented drug purchase expenditures can be obtained by comparing the size relationship of multiple segmented drug purchase expenditures. It can be understood that the maximum value refers to the largest amount of drug purchase expenditure among the multiple drug purchase expenditures.
  • S105 Obtain the insured person's medical records and drug purchase records within the time period corresponding to the maximum value
  • the terminal can communicate with the management system of the medical institution through the server, and obtain the medical records and medical records of the insured person within the time period corresponding to the maximum value from the management system of the medical institution Drug purchase records.
  • the duration of each time period is 1 month, a total of 12 time periods, and 12 time periods are 12 consecutive months within a year. If the drug purchase expenditure in July is the largest, the drug purchase expenditure in July For the maximum value, obtain the medical record and medical record of the insured in July.
  • S106 Determine whether the drug in the drug purchase record within the time period corresponding to the maximum value is related to the illness in the medical record;
  • Each medicine has a corresponding applicable illness, and the insured's medical record records the illness suffered by the insured.
  • the maximum value of the drug purchase expenditure does not exceed the preset threshold.
  • the purchase of medicines is not for the insured person, which is also an abnormal purchase behavior.
  • step S103 is executed: the medical insurance account is marked as an abnormal drug purchase target.
  • the time period corresponding to the maximum value of drug purchase expenditures in multiple periods is assumed to be the time period for the insured to purchase drugs unexpectedly. If the insured's drug purchase record in the time period is not the same as the medical record in the medical record Relevant, it means that the drug purchased by the insured person is not for itself, then it can be determined that the insured person has abnormal drug purchase behaviors of surprise drug purchase, and the medical insurance account of the insured person is marked as the object of abnormal drug purchase in order to facilitate medical insurance
  • the management unit timely recognized the insured's abnormal medical treatment behavior.
  • the method for identifying abnormal drug purchases further includes steps:
  • Step S107 is executed after step S106.
  • the drug in the drug purchase record in the time period corresponding to the maximum value is related to the illness in the medical record, it may be that a part of the drug in the drug purchase record is related to the illness in the medical record, and another part of the drug purchase record is related to the clinic
  • the symptoms in the record are not related, and it is possible that all the drugs in the drug purchase record are related to the symptoms in the medical record.
  • the correlation ratio is 1.
  • step S103 is executed: the medical insurance account is marked as an object of abnormal drug purchase.
  • the related ratio can reflect the proportion of the expenses related to the medicines in the medicine purchase records and the illnesses in the medical records in the largest amount of medicine purchase expenditures.
  • the preset ratio can be set by the medical insurance management unit. Participants may need some auxiliary treatments or auxiliary drugs that are not related to the symptoms in the medical records when they buy medicines at the doctor's visit, which will make the relevant ratio less than 1. However, if the ratio of the cost of drugs in the drug purchase record that is not related to the illness on the medical record is too large, and the cost of the drug related to the disease on the medical record is small, the drug in the drug purchase record may be It is not used to treat the insured person. This is an abnormal medical behavior.
  • a preset ratio is set, and when the relevant ratio is less than the preset ratio, the medical insurance account of the insured person is marked as an abnormal medical treatment object, so that the medical insurance staff can discover the abnormal medical treatment behavior of the insured person in time. If the relevant ratio is greater than or equal to the preset ratio, it is a normal drug purchase, and the insured person can use the medical insurance account to purchase the drug normally.
  • the method of abnormal drug purchase further includes steps:
  • S109 Generate an abnormal drug purchase report and issue an alarm reminder according to a preset method to notify the medical insurance staff in a timely manner.
  • the abnormal drug purchase report includes the insured's drug purchase expenditures, medical records, and medical bills to be settled by the medical insurance account for multiple consecutive time periods.
  • the preset method can be a pop-up window, sound and other reminder methods. For example, when an object of abnormal drug purchase is found, a voice reminder "abnormal drug purchase found" or an alarm sound of "didi" is issued.
  • the preset method is not limited to the above method. In other embodiments, it may also be another method that is convenient for reminding the medical insurance staff.
  • the terminal can communicate with the mobile phone, and when an abnormal emergency object is found, the mobile phone of the medical insurance staff Push alert reminder.
  • the present application also provides a device for identifying abnormal drug purchases.
  • the method for identifying abnormal drug purchases in any of the foregoing embodiments may be implemented by the device for identifying abnormal drug purchases in this embodiment.
  • the device for identifying abnormal drug purchases includes:
  • An acquisition module which is used to acquire the drug purchase expenditures corresponding to multiple consecutive time periods of the insured person when the insured person swipes the card to settle the medical bill;
  • a judgment module which is used to compare the drug purchase expenditure of each segment with a preset threshold to determine whether the drug purchase expenditure of a segment is greater than the preset threshold
  • the marking module is used to mark the medical insurance account as an object of abnormal drug purchase when there is a segment of drug purchase expenditure greater than a preset threshold.
  • the obtaining module includes:
  • An acquisition unit which is used to acquire the drug purchase records of the insured person for multiple consecutive time periods from the management system of each medical institution;
  • the statistical unit is used to obtain the drug purchase expenditure corresponding to each time period based on the statistics of the drug purchase records in each time period.
  • the device for identifying abnormal drug purchases also includes:
  • the first calculation module is used to calculate the sum of the drug purchase expenditures in multiple time periods to obtain the total drug purchase expenditure, and set the product of the total drug purchase expenditure and the preset coefficient as the preset threshold, where the preset coefficient is greater than 0 and less than 1.
  • the obtaining module is also used to obtain the maximum value of drug purchase expenditures in multiple segments;
  • the abnormal drug purchase identification device also includes:
  • a second calculation module which is used to calculate the average value of the remaining multiple drug purchase expenditures after removing the maximum value, and set the preset multiple of the average as a preset threshold, where the preset multiple is greater than 1 .
  • the obtaining module is further used to obtain the maximum value of the multiple drug purchase expenditures when there is no drug purchase expenditure greater than a preset threshold
  • the judgment module is also used to judge whether the medicine in the medicine purchase record within the time period corresponding to the maximum value is related to the illness in the medical record;
  • the marking module is also used to mark the medical insurance account as the object of abnormal medicine purchase when the medicine in the medicine purchase record within the time period corresponding to the maximum value is not related to the illness in the medical record.
  • the device for identifying abnormal drug purchases also includes:
  • a third calculation module which is used to calculate the value of the drug purchase record in the time period corresponding to the maximum value when the drug in the drug purchase record in the time period corresponding to the maximum value is related to the illness in the medical record.
  • the ratio of the cost of the medicine related to the disease on the medical record to the maximum value can be obtained as the relevant ratio;
  • the judgment module is also used to judge whether the relevant ratio is less than the preset ratio
  • the marking module is also used to mark the medical insurance account as an object of abnormal drug purchase when the relevant ratio is less than the preset ratio.
  • identification of abnormal drug purchases also includes:
  • the reminder module is used to generate an abnormal drug purchase report, and send an alarm reminder according to a preset method to promptly notify the medical insurance staff.
  • each module in the device for identifying abnormal drug purchase corresponds to the steps in the embodiment of the method for identifying abnormal drug purchase, and its function and implementation process will not be repeated here one by one.
  • 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.
  • the steps of the method for identifying abnormal drug purchases according to any of the foregoing embodiments are implemented.
  • 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.
  • 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.

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Abstract

L'invention concerne un procédé et un dispositif d'identification d'achat anormal de médicament, un terminal et un support de stockage lisible par ordinateur. Le procédé d'identification d'achat anormal de médicament comprend les étapes consistant à : obtenir, lorsqu'une personne assurée fait glisser une carte pour régler une facture médicale, des dépenses d'achat de médicament de période correspondant à une pluralité de périodes de temps continues de la personne assurée (S101) ; comparer chaque dépense d'achat de médicament de période avec un seuil prédéfini respectivement pour déterminer si une dépense d'achat de médicament de période supérieure au seuil prédéfini existe (S102) ; et si une dépense d'achat de médicament de période supérieure au seuil prédéfini existe, marquer le compte d'assurance médicale en tant qu'objet d'achat anormal de médicament (S103). Selon le procédé ci-dessus, il est possible de déterminer si une personne assurée a un comportement d'achat anormal de médicament consistant à acheter soudainement des médicaments en déterminant si une dépense d'achat de médicament de période supérieure à un seuil prédéfini existe et, si une dépense d'achat de médicament de période supérieure à la valeur de seuil prédéfinie existe, le compte d'assurance médicale de la personne assurée est marqué comme un objet d'achat anormal de médicament, de telle sorte que l'unité de gestion d'assurance médicale puisse identifier le comportement d'achat anormal de médicament consistant à acheter soudainement des médicaments de l'objet d'achat anormal de médicament à temps au moyen du procédé d'identification d'achat anormal de médicament et prendre des mesures correspondantes.
PCT/CN2019/096079 2018-12-13 2019-07-16 Procédé et dispositif d'identification d'achat anormal de médicament, terminal et support de stockage lisible par ordinateur Ceased WO2020119120A1 (fr)

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CN201811531072.3 2018-12-13
CN201811531072.3A CN109636651A (zh) 2018-12-13 2018-12-13 异常购药的识别方法、装置、终端及计算机可读存储介质

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CN109636651A (zh) * 2018-12-13 2019-04-16 平安医疗健康管理股份有限公司 异常购药的识别方法、装置、终端及计算机可读存储介质
CN114548207B (zh) * 2021-12-21 2025-10-21 深圳云天励飞技术股份有限公司 购药数据处理方法及装置、计算机设备、存储介质

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CN108564459A (zh) * 2018-01-09 2018-09-21 平安科技（深圳）有限公司 异常交易类型的判断方法、装置、设备及可读存储介质
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