CN106530166B - hospital medical insurance fee anti-repudiation auxiliary management information system and anti-repudiation method - Google Patents

hospital medical insurance fee anti-repudiation auxiliary management information system and anti-repudiation method Download PDF

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CN106530166B
CN106530166B CN201610797879.6A CN201610797879A CN106530166B CN 106530166 B CN106530166 B CN 106530166B CN 201610797879 A CN201610797879 A CN 201610797879A CN 106530166 B CN106530166 B CN 106530166B
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medical insurance
information
patient
unit
reimbursement
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CN106530166A (en
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但秀娟
苑萍
孙晓玮
蔡欣芸
张立佳
王晓京
王琳娜
史洁
王腊梅
陈钰
王兵
毕馨丹
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First Affiliated Hospital Chinese PLA General Hospital
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Abstract

the invention provides a hospital medical insurance charge anti-repudiation auxiliary management information system which comprises a management server and a user side, wherein the management server comprises an anti-repudiation patient database, a charge setting module, a medicine attribute setting module, a patient information identification module, a medication day prompting module, a reimbursement type setting module, a medical insurance policy information prompting module, a self-payment protocol verification module and a printing module, wherein the charge setting module is communicated with the anti-repudiation patient database. The invention can count the medication days of the patient, realizes reminding the doctor of the excessive medication days, can judge the adaptation diseases of the medicines prescribed by the doctor, and realizes reminding the doctor of the medication adaptation diseases, so that the doctor can inform the patient or family members, the possibility of expense refusal is prevented from the source, convenience is provided for the doctor, medical dispute is avoided, the hospital management is convenient, and the economic benefit brought to the hospital is obvious.

Description

Hospital medical insurance fee anti-repudiation auxiliary management information system and anti-repudiation method
Technical Field
the invention belongs to the technical field of medical systems, and particularly relates to a hospital medical insurance fee anti-repudiation auxiliary management information system and an anti-repudiation method.
Background
The basic medical guarantee system is a component of a social guarantee system, is also an important content of the health care industry, is closely related to vital interests of people, and along with continuous reformation and perfection of the social guarantee system in China, people covered by medical insurance are more and more extensive, on one hand, medical requirements of people who are pressed are further released, and on the other hand, hospitals are rapidly developed, so that the responsibility and pressure of medical insurance management institutions and hospital medical insurance managers on the aspect of medical insurance cost control are more and more increased. The cost problem of the medical insurance patient is always one of the focuses of the common attention of the patient, the medical insurance management institution and the hospital, and the medical insurance management institution sets corresponding management measures for ensuring the safety of the fund, so that the basic medical treatment is ensured and the expenditure of the fund is reduced as much as possible; in order to achieve the development of the medical service provider, hospitals are expected to maximize and rationalize the service benefits and minimize the occurrence of medical insurance repudiation, and the medical insurance cost repudiation becomes the most prominent contradiction and problem which restricts the development of the hospitals and influences the doctor-patient relationship and the establishment of a harmonious society.
The hospital is an executor of medical insurance policies and systems, the medical service effect provided by the hospital for insured personnel directly influences the success or failure of the medical insurance policies and systems and influences the trust degree of the insurers and the medical insurance policies, so the hospital plays a very important role in the medical insurance policy execution process, and the front-line clinician is used as a direct administrator of the medical insurance cost and bears the main responsibility of medical insurance cost management, however, the phenomenon that the patient refuses to pay the medical insurance cost occurs sometimes, and the reason is mainly divided into the following points: 1) doctors have inaccurate medical insurance policy control and do not comprehensively control policy differences among different dangerous species; 2) the medicine types of doctors exceed the medical insurance range; 3) the dosage of the medicine exceeds the regulated dosage; 4) when self-paid or partially self-paid medicines or medical items are used, the obligation to inform the patient or family members is not exhausted, and no informed consent is signed. Therefore, the above reasons easily cause the condition of refusal of medical charge, which brings adverse consequences to hospitals and severely limits the development of hospitals, and the prior patent publication No. CN104008449A discloses a hospital care patient management system which can effectively manage the medical care information of hospital care patients, provides convenience for the hospitals to manage the information of the hospital care patients, but still does not solve the problem of refusal of medical care, so that the hospitals urgently need to develop an assistant management information system and a method for preventing refusal of medical care charge of hospitals, which can prompt doctors about information such as overdose information of medication days, whether medication is an indication, whether patients or family members sign self-care agreements, and the like, and prevent the condition that patients refuse medical care charge from occurring.
Disclosure of Invention
In order to solve the problem that in the prior art, because doctors have inaccurate medical insurance policy control, the policy difference between different dangerous species is not comprehensively controlled; the medicine types of doctors exceed the medical insurance range; the dosage of the medicine exceeds the regulated dosage; the invention provides a hospital medical insurance charge anti-refusal auxiliary management information system and an anti-refusal method, wherein when self-payment or partial self-payment medicines or diagnosis and treatment items are used, the conditions of refusal of medical charge and the like caused by informing a patient or family members are not completed and an informed consent is not signed.
The specific technical scheme of the invention is as follows:
the invention provides a hospital medical insurance charge anti-repudiation auxiliary management information system, which comprises a management server and a user side, wherein the user side accesses the management server through a WEB application program, the management server is respectively in communication link with a hospital information system server and a local medical insurance information system server, the management server comprises an anti-repudiation patient database, and the anti-repudiation patient database is in communication link with a medical insurance drug directory library and a national basic drug directory library;
the management server also comprises a charge setting module, a drug attribute setting module, a patient information identification module, a medication day prompting module, a reimbursement type setting module, a medical insurance policy information prompting module, a self-charge protocol verification module and a printing module which are communicated with the anti-refusal patient database; the anti-refusal patient database is internally stored with patient identity data, and the identity data comprises a patient name, an ID number, hospitalization time, a treating physician and a fee type; the fee setting module presets the fee types according to medical insurance types, wherein the fee types comprise medical insurance fee types and non-medical insurance fee types; the drug attribute setting module is used for setting drug attributes, the drug attribute setting module is in communication link with the fee setting module, and the drug attributes are mapped with the fee types;
the patient information identification module identifies whether the patient participates in the insurance and the dangerous type of the insurance according to the fee type of the patient and sends the patient to the medication day prompting module;
The medication day prompting module comprises a medication day limiting preset unit, an actual medication day calculating unit and a medication prompting unit, wherein the medication day limiting preset unit determines a medication day limiting number according to the patient participation category and the risk category identified by the patient information identification module and sends the medication day limiting number to the medication prompting unit;
the reimbursement type setting module is used for setting reimbursement types of the medicines and the diagnosis and treatment items and displaying the reimbursement types on a user side; the medical insurance policy information prompting module generates a prompting frame containing prompting information and sends the prompting frame to a user side, wherein the prompting information comprises one or more of medicine taking according to medicine indications, medicine taking according to the regulation of a medicine specification and whether the prompting information is a post-issuance text with the indications or not; the self-fee agreement verifying module is used for verifying whether a self-fee agreement exists; the printing module is used for distinguishing non-self-fee medicines from self-fee medicines, respectively generating a prescription order of the medical insurance medicines and a prescription order of the self-fee medicines, and simultaneously printing the prescription.
further, the management server also comprises an information updating module communicated with the anti-refusal patient database, the information updating module comprises an access unit, an acquisition unit, an information analysis unit, a sequencing unit and an information updating unit which are communicated,
The access unit respectively accesses the hospital information system server and the local medical insurance information system server according to the URL address or the IP address and preset time intervals; the acquisition unit is used for acquiring the publishing time attribute information and the page attribute information of the publishing pages in the hospital information system server and the local medical insurance information system server and sending the publishing time attribute information and the page attribute information to the information analysis unit; the information analysis unit is used for comparing the release time attribute information with the page attribute information, sending the release pages with the change of the release time attribute information to the sorting unit if the information changes, comparing the page attribute information of the release pages obtained twice adjacently, and sending the release pages with the change of the page characters exceeding the preset proportion to the sorting unit if the change of the page characters exceeds the preset proportion; the sorting unit establishes a queue according to attribute information to sort and send the queue to the information updating unit, wherein the attribute information comprises one or more of URL (uniform resource locator), IP (Internet protocol) address, server name, medical insurance department and release time; and the information updating unit confirms the actually updated release page in the queue according to the instruction of a manager, and automatically acquires and stores the medical insurance reimbursement policy information of the re-edited release page in the anti-refusal patient database.
Further, the management server further comprises a prescription list generation module communicated with the patient refusal payment prevention database, wherein the prescription list generation module comprises a query unit, an entry unit and a distribution unit which are communicated with one another, the query unit is used for automatically querying medicines in the medical insurance medicine catalogue library and the national basic medicine catalogue library according to keywords and sending the queried medicines to the entry unit, and the keywords comprise one or two combinations of medicine names and medicine indications; the input unit is used for providing a medicine input interface, generating a prescription list from the inquired and input diagnosis and treatment items and sending the prescription list to the distribution unit; the prescription distribution unit is used for carrying out prescription distribution processing on the prescription list to generate a medical insurance medicine prescription list and a self-payment medicine prescription list.
furthermore, the management server also comprises a charge management module communicated with the patient refusal payment prevention database, the charge management module comprises a project charge settlement unit, a reimbursement charge settlement unit, a charge comparison unit and a charge reminding unit,
The project cost settlement unit is used for carrying out cost statistics on the total number of diagnosis and treatment projects and the total number of medicines to obtain a project total cost W and sending the calculated project total cost W to the cost comparison unit, and a calculation formula of the project total cost W is as follows:
W＝n1A1+n2A2+...niAi+m1B1+m2B2+...+mjBj
Wherein, W is the total cost of the project; i is the number of items of the diagnosis and treatment items; ai is the unit price of the ith diagnosis and treatment item; ni is the number of the ith diagnosis and treatment item; j is the number of the types of the medicines, Bj is the unit price of the jth medicine, and mj is the number of the jth medicine;
The reimbursement expense settlement unit performs expense reimbursement statistics on the total amount of the medicines and the diagnosis and treatment items marked in the prescription bill according to the medical insurance medicine catalogue library to obtain total reimbursement expense Y, and sends the calculated total reimbursement expense Y to the expense comparison unit, wherein the calculation formula of the total reimbursement expense Y is as follows:
Y＝(n1×A1×K1)+(n2×A2×K2)+...+(ni×Ai×Ki)+(m1×B1×H1)
+(m2×B2×H2)+...+(mj×Bj×Hj)
Wherein Y is total reimbursement cost; i is the number of items of the diagnosis and treatment items; ai is the unit price of the ith diagnosis and treatment item; ni is the number of the ith diagnosis and treatment items, and ni is less than or equal to the maximum number value of reimbursement of the diagnosis and treatment items recorded in the medical insurance drug catalogue library; ki is the reimbursement proportion of the ith diagnosis and treatment item; j is the number of the types of the medicines, Bj is the unit price of the jth medicine, mj is the number of the jth medicine, and mj is less than or equal to the maximum reimbursement quantity value of the medicines recorded in the medical insurance medicine catalogue library; hj is the reimbursement proportion of the jth drug;
The cost comparison unit compares the calculated total project cost W with the total reimbursement cost Y, if the total project cost W is larger than the total reimbursement cost Y, the cost comparison unit sends a reminding instruction to the cost reminding unit, and the cost reminding unit generates a reminding message for indicating whether the total project cost exceeds the total reimbursement cost and continues or not and sends the reminding message to the user side.
Preferably, the patient information identification module comprises an identification unit of dangerous case, a screening unit of dangerous case and an information matching unit which are communicated with the anti-refusal patient database, the dangerous type identification unit is used for matching the patient identity data in the patient refusal payment prevention database with the patient identity data stored in the local medical insurance information system server, inquiring the insurance participation information of the patient and sending the insurance participation information to the dangerous type screening unit, the dangerous seed screening unit automatically recommends the dangerous seeds selected by the patients according to one or more dimensions of preset minimum hospital expenditure, minimum patient expenditure, minimum diagnosis and treatment time, minimum insurance consumption, a preset balance ratio of hospital and patient expenditure and the types of diseases, sends the selected dangerous seeds to the information matching unit, the information matching unit is used for establishing a mapping relation between the patient refusal payment prevention database and the medical insurance drug catalogue library as a common matching field through dangerous seeds;
Preferably, the medical insurance policy information prompting module further comprises a medicine specification reading unit, a medical insurance information identifying unit and a quick reading unit which are communicated with each other, wherein the medicine specification reading unit is used for reading the medicine specification information in the medical insurance medicine catalogue library, generating an electronic medicine specification and sending the electronic medicine specification to the medical insurance information identifying unit, the medical insurance information identifying unit is used for setting at least one medical insurance identifying area in the electronic medicine specification, and each medical insurance identifying area highlights the character information of taking medicine according to the medicine indication or the dosage specified by the specification; the quick reading unit is used for extracting the medical insurance identification area in the electronic medicine specification and generating a brief electronic medicine specification taking the medical insurance identification area as a main part.
the invention also provides a hospital medical insurance cost refusal payment prevention method applying the hospital medical insurance cost refusal payment prevention auxiliary management information system, which comprises the following steps:
s1, fee setting: setting fee types in advance according to medical insurance types, wherein the fee types comprise medical insurance fee types and non-medical insurance fee types;
s2, setting the drug attribute: setting drug attributes, and mapping the drug attributes with the charge types, wherein the drug attributes comprise self-charge attributes and non-self-charge attributes, the non-self-charge attributes comprise non-self-charge drug information read from a medical insurance drug directory library, the self-charge attributes comprise self-charge drug information read from a national basic drug directory library, and the self-charge drug information and the non-self-charge drug information respectively comprise one or more of drug names, drug application symptoms, drug usage and contraindication drug information;
s3, identifying the patient participation insurance category and the dangerous case: distinguishing whether the patient participates in the insurance and the risk types of the insurance according to the fee classification type of the patient;
S4, setting a prompt by calculating the medication days of the patient:
s4-1, setting the number of medication limit days: determining a defined number of days to administer based on the patient participation category and risk identified in step S3;
s4-2, calculating the actual medication days: automatically calculating the actual medication days of the medicine according to the usage and the dosage of the medicine which is actually prepared by a doctor and is used for a patient;
S4-3, setting prompt information: when the actual number of days for medication calculated in step S4-2 is greater than the limited number of days for medication set in step S4-1, issuing a prompt message of "excessive unprinted dialog" to the doctor;
S5, setting reimbursement categories of medicines and diagnosis and treatment items: setting and displaying reimbursement categories of medicines and diagnosis and treatment items for reference of doctors: dividing diagnosis and treatment items and medicines into three kinds of reimbursement items, namely a first kind of items, a second kind of items and a third kind of items according to reimbursement ranges, wherein the first kind of items are medicines and diagnosis and treatment items which are totally brought into the medical insurance reimbursement ranges; the class B item is a medicine and diagnosis and treatment item with self-fee ratio limitation, and part of medicines have the limitation of indications; the class C items are medicine and diagnosis and treatment items which need full self-charge;
s6, medical insurance reimbursement policy information prompt of medicine and diagnosis and treatment items is set: prompting a doctor through a prompt box containing prompt information, wherein the prompt information comprises one or more of medicine taking according to medicine indications, medicine taking according to the regulation of a medicine specification and whether the medicine is a post-price postissuance letter with the indications;
S7, self-fee agreement verification: when a doctor prescribes self-fee medicines for a patient, verifying whether a self-fee protocol exists;
s8, setting the printing of the squares: when doctors provide self-fee medicines and non-self-fee medicines for patients at the same time, the prescriptions are automatically divided and printed into prescription forms of medical insurance medicines and self-fee medicines.
further, the method also comprises updating medical insurance reimbursement policy information, and the specific updating method comprises the following steps:
Accessing and acquiring: according to the URL address or the IP address, accessing a server for issuing medical insurance policy information according to a preset time interval, and acquiring issuing time attribute information and page attribute information of an issuing page in the server, wherein the server comprises a local medical insurance information system server and a hospital information system server;
Comparison and analysis: comparing the release time attribute information of the release pages acquired at two adjacent times, if the information is not changed, terminating the updating, otherwise, entering the next step; comparing the page attribute information of the issued pages acquired in two adjacent times, comparing the proportion of page character change, if the proportion does not exceed the preset proportion, terminating the updating, otherwise, entering the next step;
Establishing a queue: acquiring the release pages with the change of the release time attribute information and the release pages with the change ratio of page characters in the page attribute information exceeding a preset ratio, and establishing a queue for sequencing according to the attribute information, wherein the attribute information comprises one or more of URL (uniform resource locator), IP (Internet protocol) address, server name, medical insurance department and release time;
Fourthly, updating the medical insurance reimbursement policy information: and according to the instruction of a manager, confirming the actually updated release page in the queue, and automatically acquiring and storing the medical insurance reimbursement policy information of the re-edited release page.
Further, the method also comprises the step of generating a prescription list, and the specific method is as follows:
Firstly, drugs are inquired in the medical insurance drug directory library and the national basic drug directory library through keywords according to the symptoms of the patients, wherein the keywords comprise one or two combinations of drug names and drug indications;
secondly, generating a prescription list for the medicines inquired in the first step and the diagnosis and treatment items input by the doctor;
and thirdly, the prescription order generated in the step two is divided to generate a medical insurance medicine prescription order and a self-payment medicine prescription order.
Further, the method comprises the following steps: and settling the cost of the medicines or the diagnosis and treatment items on the prescription order, comparing the settled cost with a cost threshold value for reimbursement of medical insurance reimbursement policy information, and if the settled cost exceeds the cost for reimbursement of the medical insurance reimbursement policy information, generating a prompt instruction to prompt a doctor to inform the doctor to a patient or a family member, wherein the cost calculation comprises the following steps:
calculating the total item cost W of the total amount of medicines and diagnosis and treatment items in the prescription list by the following formula:
W＝n1A1+n2A2+...niAi+m1B1+m2B2+...+mjBj
wherein, W is the total cost of the project; i is the number of items of the diagnosis and treatment items; a. theithe unit price of the ith diagnosis and treatment item; n isithe number of the ith diagnosis and treatment items is; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjthe number of jth drug;
secondly, according to the medical insurance reimbursement policy information, performing expense reimbursement statistics on the total amount of the medicines and the diagnosis and treatment items marked in the prescription list through the following formula to obtain total reimbursement expense Y:
Y＝(n1×A1×K1)+(n2×A2×K2)+...+(ni×Ai×Ki)+(m1×B1×H1)
+(m2×B2×H2)+...+(mj×Bj×Hj)
Wherein Y is total reimbursement cost; i is the number of items of the diagnosis and treatment items; a. theithe unit price of the ith diagnosis and treatment item; n isiIs the number of the ith diagnosis and treatment item, niThe maximum number value of reimbursement of the diagnosis and treatment items recorded in the medical insurance reimbursement policy information is less than or equal to; kiThe reimbursement proportion of the ith diagnosis and treatment item is obtained; j is the number of the types of the drugs, BjIs the unit price of the jth drug, mjnumber of jth drug, mjthe maximum quantity value of reimbursement of the medicines recorded in the medical insurance reimbursement policy information is less than or equal to; hjThe reimbursement proportion of the jth drug;
Comparing the total project cost W with the total reimbursement cost Y, if the total project cost W is larger than the total reimbursement cost Y, sending a prompt message of 'whether the total project cost exceeds the total reimbursement cost and continues' to a doctor, and if the total project cost W is smaller than or equal to the total reimbursement cost Y, not prompting.
preferably, the identification of the patient risk category in step S3 further comprises the steps of:
Calling a plurality of patient identity data in the local medical insurance information system server to be matched with the identity data in the patient transfer prevention database where the current patient is located, and inquiring the insurance participation information of the patient;
identifying and confirming that the patient is suitable for a certain dangerous type, namely updating or generating the dangerous type attribute information of the patient in the anti-refusal patient database; when the patient is identified to be suitable for a plurality of dangerous species, the system automatically pushes out a selection interface, the third step is carried out after the dangerous species is manually selected, and the fourth step is carried out otherwise;
Establishing a mapping relation between the patient refusal payment prevention database and the medical insurance drug catalogue library by taking the dangerous species as a common matching field;
fourthly, automatically recommending the dangerous species selected by the patient according to one or more dimensions of preset minimum hospital expenditure, minimum patient expenditure, minimum diagnosis and treatment time, minimum insurance consumption, preset balance ratio of hospital and patient expenditure and the types of diseases, and then executing the third step;
Preferably, the prompting method in step S6 includes:
Reading medicine specification information from the medical insurance medicine directory library to generate an electronic medicine specification;
setting at least one medical insurance identification area in the electronic medicine instruction book, wherein each medical insurance identification area highlights character information for taking medicine according to medicine indications or the dosage specified by the instruction book;
Setting a quick reading option, and only providing a brief electronic medicine specification which mainly comprises the medical insurance identification area when the quick reading option is started.
the invention has the following beneficial effects: the system provided by the invention can update the medical insurance reimbursement policy information in time, can count the number of days of medication of patients, realizes that the number of days of medication exceeds the number of days of medication to remind doctors, can judge the adaptation diseases of medicines prescribed by doctors simultaneously, realizes that the patients are reminded of medication without symptoms, can verify self-payment protocol before the prescription is generated, comprehensively and timely reminds the doctors to inform the patients or family medicines or diagnosis and treatment items of exceeding the medical insurance reimbursement range, prevents the possibility of charge refusal from the source, improves the communication and understanding between doctors and patients simultaneously, obviously improves the trust and satisfaction of the patients to hospitals, and can ensure that medical staff can accurately grasp the application range and the dosage of prescribed medicines, further ensures that the medical insurance policy is easier to understand and cooperate in execution, and provides convenience for the doctors, the method provided by the invention can be used for timely inputting information and updating medical insurance reimbursement policy information, quickly and accurately calculating the dosage, judging medication adaptation diseases, realizing the overdose reminding, the non-symptomatic reminding and the like of the dosage, timely reminding a doctor to inform patients or family members, avoiding the possibility of expense refusal, and being convenient to use and strong in practicability.
Drawings
FIG. 1 is a schematic structural diagram of a hospital medical insurance cost anti-repudiation auxiliary management information system according to embodiment 1;
FIG. 2 is a flow chart illustrating the structure of a management server in the hospital medical insurance cost anti-repudiation auxiliary management information system according to embodiment 1;
FIG. 3 is a flow chart illustrating the structure of an information update module in the hospital medical insurance cost anti-repudiation auxiliary management information system according to embodiment 2;
FIG. 4 is a flow chart illustrating the structure of a prescription generating module in the hospital medical insurance charge anti-repudiation auxiliary management information system according to embodiment 3;
FIG. 5 is a flow chart illustrating the structure of the charge management module in the hospital medical insurance charge denial prevention auxiliary management information system according to embodiment 3;
FIG. 6 is a flow chart illustrating the structure of a patient information identification module in the hospital medical insurance cost anti-repudiation auxiliary management information system according to embodiment 4;
fig. 7 is a flowchart illustrating a structure of a medical insurance policy information prompting module in the hospital medical insurance cost denial prevention auxiliary management information system according to embodiment 4.
Wherein: 1. a management server; 101. a patient refusal prevention database; 102. a fee setting module; 103. a drug attribute setting module; 104. a patient information identification module; 1041. a dangerous seed identification unit; 1042. a dangerous seed screening unit; 1043. an information matching unit; 105. a medication day prompting module; 1051. a preset unit for limiting medication days; 1052. a practical medication day calculation unit; 1053. a medication reminding unit; 106. a reimbursement type setting module; 107. a medical insurance policy information prompting module; 1071. a drug order reading unit; 1072. a medical insurance information identification unit; 1073. a fast reading unit; 108. a self-fee protocol verification module; 109. a printing module; 110. an information updating module; 1101. an access unit; 1102. an acquisition unit; 1103. an information analysis unit; 1104. a sorting unit; 1105. an information updating unit; 111. a prescription generating module; 1111. a query unit; 1112. a recording unit; 1113. a squaring unit; 112. a fee management module; 1121. a project fee settlement unit; 1122. a reimbursement charge settlement unit; 1123. a cost comparison unit; 1124. a charge reminding unit; 2. a user side; 3. a hospital information system server; 4. local medical insurance information system server.
Detailed Description
The present invention will be described in further detail with reference to the following examples and drawings.
example 1
as shown in fig. 1 or 2, an auxiliary management information system for preventing hospital medical insurance cost from being refused includes a management server 1 and a user end 2, the user end 2 accesses the management server 1 through a WEB application program, the management server 1 is respectively in communication link with a hospital information system server 3 and a local medical insurance information system server 4, the management server 1 includes a patient database 101 for preventing refused payment, and the patient database 101 for preventing refused payment is in communication link with a medical insurance drug directory library and a national basic drug directory library. The user end 2 comprises a PC end and a mobile phone end, and the doctor accesses the management server 1 through a WEB application program of the user end 2 and reads or receives data information of the management server 1. The hospital information system server 3 is a military guard one number information system, the management server 1, the hospital information system server 3 and the local medical insurance information system server 4 of the military guard one number respectively establish a link path, and can access in real time, and meanwhile, medical insurance policy information issued by the hospital information system server 3 and the local medical insurance information system server 4 of the military guard one number is embedded into the management server 1, so that doctors can know medical insurance policy information in time to meet requirements of medical insurance regulations.
In addition, the medical insurance drug catalogue library records local medical insurance drug reimbursement catalogues, and the national basic drug catalogue library is the basis for the medical institutions to prepare and use drugs and comprises a basic medical health institution preparation and use part and other medical institution preparation and use parts. The medicines in the basic medicine catalog are suitable for basic medical and health requirements, have proper dosage forms and reasonable price, can ensure supply and can be fairly obtained by the public. The anti-denial patient database 101 is linked with the medical insurance drug catalog library and the national basic drug catalog library to realize the function of reading the medical insurance drugs and the national basic drugs.
as shown in fig. 2, the management server 1 further includes a charge setting module 102, a drug property setting module 103, a patient information identification module 104, a medication day prompting module 105, an reimbursement type setting module 106, a medical insurance policy information prompting module 107, a self-payment protocol verification module 108, and a printing module 109, which are in communication with the anti-denial patient database 101.
note that the anti-denial patient database 101 stores therein patient identification data including patient name, ID number, time of stay, physician and type of fee.
The fee type setting module 102 sets the fee type in advance according to the medical insurance type, wherein the fee type comprises a medical insurance fee type and a non-medical insurance fee type, the non-medical insurance fee type is not referred to, and the medical insurance fee type is divided into a local medical insurance, a medical personnel, a birth insurance, a work injury insurance, a student medical insurance, an old medical insurance, an unemployed medical insurance, a public medical insurance and a military medical insurance. The drug attribute setting module 103 is used for setting drug attributes, the drug attribute setting module 103 is in communication link with the fee setting module 102, and the drug attributes are mapped with the fee types; the method comprises the steps that different charge types are different in corresponding medicine attribute, the medicine attribute can be selected through the charge types, the medicine attribute comprises self-charge attribute and non-self-charge attribute, the non-self-charge attribute comprises non-self-charge medicine information read from a medical insurance medicine catalogue library, the self-charge attribute comprises self-charge medicine information read from a national basic medicine catalogue library, and the self-charge medicine information and the non-self-charge medicine information respectively comprise one or more of medicine name, medicine application symptoms, medicine usage and contraindication medicine information.
it should be noted that, the patient information identification module 104 identifies whether the patient participates in the insurance and the risk category of the insurance according to the fee type of the patient, and sends the patient to the medication day prompting module 105; the number of medication-limiting days can be determined by determining the patient's risk categories and the patient's condition.
For the type of charge, when the medical insurance related information prompt box is used specifically, for example, when the insurance of the industrial injury is selected, the information in the prompt box is that "the diagnosis on the 'industrial injury certificate' is strictly needed for treatment, if the medical insurance does not belong to the treatment of the industrial injury and other diseases caused by the industrial injury, the medical insurance is separately inpatient or outpatient treatment, which is convenient for reminding a doctor to select the proper type and risk type of charge so as to prevent the occurrence of the condition of refusal of payment.
The medicine medication day reminding specifically comprises the following steps: the medication day prompting module 105 comprises a limited medication day presetting unit 1051, an actual medication day calculating unit 1052 and a medication reminding unit 1053, wherein the limited medication day presetting unit 1051 determines a limited medication day according to the patient insurance category and the risk category identified by the patient information identification module 104, sends the limited medication day to the medication reminding unit 1053, and provides medicines according to the emergency 3 days, the outpatient 7 days, the two weeks with inconvenient movement and ten kinds of specified chronic diseases which are specified by medical insurance and do not exceed 1 month. The actual medication days calculation unit 1052 automatically calculates the actual medication days of the medicine according to the usage and the dosage of the medicine actually prepared by the doctor for the patient, and sends the actual medication days to the medication reminding unit 1053.
The actual days taken was calculated by the following formula:
Wherein T is the actual medication days of the patient; d is the total dosage of the medicine which is prescribed by the doctor to the patient; a is the number of times of administration of the medicine for the patient each day; q is the dosage of the patient for each time.
The medication reminding unit 1053 is used for comparing the actual medication days with the limited medication days, and if the actual medication days are larger than the limited medication days, the medication reminding unit 1053 generates prompt information of an 'excessive unprinted dialog box' and sends the prompt information to the user side 2.
For example: the prescription amount is specified by a medical insurance center in a certain market as follows: firstly, acute patients should not exceed 3 days; secondly, the chronic diseases are not more than 7 days; the mobility inconvenience does not exceed 2 weeks; thirdly, the patient suffering from ten chronic diseases such as hypertension, diabetes and the like needs to take the same medicine for a long time when the condition is stable, and the dosage can be widened to one month; fourthly, the general condition of outpatient emergency treatment of the patients with the industrial injury insurance is that the prescription dose is 2 weeks; the dosage of the medicament for the special conditions of paraplegia, amputation and the like does not exceed 1 month at most. For example, if the prescribed dosage is exceeded, the exceeding cost is inevitably generated, therefore, when the doctor sets up a prescription order, the doctor is provided in time, thereby being convenient for the doctor to inform the patient or family members, the exceeding dosage needs self-payment cost, and the later condition of cost refusal or medical dispute is avoided.
the reminding of the number of days for taking medicine can prevent the amount of medicine given by the doctor from exceeding the medical insurance reimbursement range, and effectively remind the doctor, so that the doctor can conveniently and reasonably control the amount or items of the medicine, the treatment cost of the patient is saved, and the expense refusal is avoided.
the reimbursement type setting module 106 is used for setting reimbursement types of the medicines and the diagnosis and treatment items and displaying the reimbursement types on the user terminal 2; a doctor can select medicines and diagnosis and treatment items through a user side 2, different medicines and diagnosis and treatment items have different reimbursement categories, the reimbursement category setting module 106 divides the diagnosis and treatment items and medicines into three reimbursement item categories of a class A item, a class B item and a class C item according to reimbursement ranges, and the class A item is a medicine and diagnosis and treatment item with full amount brought into the medical insurance reimbursement range; the class B item is a medicine and diagnosis and treatment item with self-fee ratio limitation, and part of medicines have the limitation of indications; the third-class project is a medicine and diagnosis and treatment project which needs full self-charge.
the medical insurance policy information prompting module 107 generates a prompting frame containing prompting information and sends the prompting frame to the user end 2, wherein the prompting information comprises one or more of medication according to medicine indications, medication according to the regulation of a medicine specification, and whether the prompting information is a post-issuance document with the indication; data are dynamically imported from a medical insurance drug catalogue library to judge drug indications of patients, the prompting function can intuitively and conveniently prompt doctors to take drugs according to the indications, and the problem of drug taking specified by the medical insurance catalogue is well controlled. The doctor can be intuitively and conveniently prompted to take the medicine according to the prescription of the medicine specification, and the problem of the prescription of the super-medicine specification is well solved. Whether the post-issuance of the price is marked with the indications: the technical scheme can better solve the problems that the scope of the excess commodity price regulation and the supplement regulation are not known and the problem occurs.
medical insurance management stipulations: for the items of the total self-fees outside the medical insurance drug catalogue library and the items of the self-fee proportion in the medical insurance drug catalogue library, before use, a self-fee agreement must be signed with a patient or a family member, if the hospital does not inform the self-fee items of the medical insurance patient in advance, once the cost is disputed, therefore, in order to remind a doctor to prevent forget to sign the self-fee agreement with the patient or the family member, a self-fee agreement verification module 108 is designed in the technical scheme, the self-fee agreement verification module 108 is used for verifying whether the self-fee agreement exists or not, if the self-fee agreement does not exist, the doctor is reminded, and the self-fee agreement can be scanned by a scanner and then uploaded to a system for verification, so that convenience is provided for the hospital by the self-fee agreement, and the phenomenon that the doctor or the hospital pays the medical expenses is avoided.
when a prescription is made for a patient in medical insurance, the medicine in the medical insurance medicine catalogue library uses a medical insurance special prescription, the disease diagnosis record on the prescription must be consistent with the medication, the self-fee prescription must be separately made for the self-fee medicine, and the self-fee medicine is printed separately from the medicine in the medical insurance. The prescription is printed separately, so that the self-payment medicine and the non-self-payment medicine can be checked more intuitively, the patient can be clearer to prevent the patient from refusing payment, and the patient can communicate with a doctor in time when the patient has a question, so that the condition of refusing payment is avoided.
Example 2
As shown in fig. 3, in embodiment 2 of the present invention, based on embodiment 1, the management server 1 further includes an information updating module 110 in communication with the anti-denial patient database 101, where the information updating module 110 includes an accessing unit 1101, an obtaining unit 1102, an information analyzing unit 1103, a sorting unit 1104, and an information updating unit 1105 in communication. By the technical scheme, the medical insurance policy information is updated in real time, and the medical insurance or commodity price part can update the medical insurance policy information in the patient refusal prevention database 101 according to actual conditions at any time, so that a foundation is provided for later data statistics and reminding.
The access unit 1101 respectively accesses the hospital information system server 3 and the local medical insurance information system server 4 according to a URL address or an IP address at preset time intervals; the acquiring unit 1102 is configured to acquire the distribution time attribute information and the page attribute information of the distribution pages in the hospital information system server 3 and the local medical insurance information system server 4, and send the information to the information analyzing unit 1103; the information analysis unit 1103 is configured to compare the release time attribute information with page attribute information, and if the information changes, send the release page with the change in the release time attribute information to the sorting unit 1104, where the information analysis unit 1103 is further configured to compare the page attribute information of the release pages acquired twice in a neighboring manner, and if the ratio of page character change exceeds a preset ratio, send the release page with the ratio of page character change exceeding the preset ratio to the sorting unit 1104; the sorting unit 1104 establishes a queue according to attribute information to sort and send the queue to the information updating unit 1105, wherein the attribute information includes one or more of URL, IP address, server name, medical insurance department and release time; the information updating unit 1105 confirms the release page that is actually updated in the queue according to the instruction of the administrator, and automatically acquires and stores the medical insurance reimbursement policy information of the re-edited release page in the anti-denial patient database 101.
Example 3
as shown in fig. 4, embodiment 3 of the present invention defines that, on the basis of embodiment 1, the management server 1 further includes a prescription list generating module 111 in communication with the anti-denial patient database 101, where the prescription list generating module 111 includes a query unit 1111, an entry unit 1112, and a dispensing unit 1113 in communication, and the query unit 1111 is configured to automatically query the medical insurance drug catalog library and the national basic drug catalog library for drugs according to keywords, and send the queried drugs to the entry unit 1112, where the keywords include one or a combination of drug names and drug indications; the entry unit 1112 is configured to provide a drug entry interface, generate a prescription list from the inquired and entered diagnosis and treatment items, and send the prescription list to the prescription unit 1113; the prescription distribution unit 1113 is used for distributing the prescription to generate a prescription of a medical insurance medicine and a prescription of a self-payment medicine.
according to the technical scheme, a doctor can conveniently inquire medicines in the medical insurance medicine catalogue library and the national basic medicine catalogue library, and can enter the medicines or diagnosis and treatment items through the entry unit 1112, so that an electronic prescription list is generated and processed in a distributed mode, and self-fee or non-self-fee medicines or diagnosis and treatment items can be clearly displayed, so that the medicines or diagnosis and treatment items can be conveniently displayed for a patient or can remind the patient.
As shown in fig. 5, it should be noted that, in addition to counting the number of days of medication and reminding a doctor, the present invention can remind the doctor to notify a patient by the medication cost exceeding the medical insurance cost, so as to avoid refusal of payment, for this reason, the management server 1 is defined in the present technical solution to further include a cost management module 112 communicating with the patient database 101 for refusal of payment, where the cost management module 112 includes an item cost settlement unit 1121, a reimbursement cost settlement unit 1122, a cost comparison unit 1123, and a cost reminding unit 1124,
The item cost settlement unit 1121 is configured to perform cost statistics on the total number of diagnosis and treatment items and the total number of medicines to obtain an item total cost W, and send the calculated item total cost W to the cost comparison unit 1123, where a calculation formula of the item total cost W is as follows:
W＝n1A1+n2A2+...niAi+m1B1+m2B2+...+mjBj
wherein, W is the total cost of the project; i is the number of items of the diagnosis and treatment items; a. theithe unit price of the ith diagnosis and treatment item; n isiThe number of the ith diagnosis and treatment items is; j is the number of the types of the drugs, BjIs the unit price of the jth drug, mjThe number of jth drug;
the reimbursement charge settlement unit 1122 performs charge reimbursement statistics on the total amount of the medicines and the diagnosis and treatment items marked differently in the prescription order according to the medical insurance medicine catalogue library to obtain a total reimbursement charge Y, and sends the calculated total reimbursement charge Y to the charge comparison unit 1123, wherein the calculation formula of the total reimbursement charge Y is as follows:
Y＝(n1×A1×K1)+(n2×A2×K2)+...+(ni×Ai×Ki)+(m1×B1×H1)
+(m2×B2×H2)+...+(mj×Bj×Hj)
wherein Y is total reimbursement cost; i is the diagnosis and treatment itemThe number of items; a. theiThe unit price of the ith diagnosis and treatment item; n isiIs the number of the ith diagnosis and treatment item, niThe maximum number value of reimbursement of the diagnosis and treatment items recorded in the medical insurance drug catalogue library is less than or equal to; kiThe reimbursement proportion of the ith diagnosis and treatment item is obtained; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjNumber of jth drug, mjThe maximum number value of reimbursement of the medicines recorded in the medical insurance medicine catalogue library is less than or equal to; hjThe reimbursement proportion of the jth drug;
The cost comparison unit 1123 compares the calculated total cost W of the project with the total reimbursement cost Y, if the total cost W of the project is greater than the total reimbursement cost Y, the cost comparison unit 1123 sends a reminding instruction to the cost reminding unit 1124, and the cost reminding unit 1124 generates a prompt message indicating whether the total cost of the project exceeds the total reimbursement cost and continues to send the prompt message to the user end 2.
example 4
In embodiment 4 of the present invention, based on embodiment 1, a patient information identification module 104 and a medical insurance policy information prompt module 107 are further defined.
As shown in FIG. 6, since there are many medical insurance types and policy rules between different risk types are different, doctors are not easy to grasp policy differences between different risk types completely, it is difficult to manage them according to different categories as required, and it is also impossible to select the optimal risk type for the patient to reimburse, for example, the risk type of industrial injury is only responsible for paying the hospitalization cost of the industrial injury disease, the cost of the disease exceeding the approved range will result in refusal, the birth insurance will pay according to the disease type, the limit will result in refusal, and the two reimbursement systems are different, for this reason, it is preferable that the patient information identification module 104 in this technical solution includes a risk type identification unit 1041 communicating with the patient refusal prevention database 101, a risk type screening unit 1042, and an information matching unit, the risk type identification unit 1041 is used for comparing the patient identification data in the patient refusal prevention database 101 with the patient identification number stored in the local medical insurance information system server 4 According to the matching, the insurance information of the patient is inquired and sent to a dangerous type screening unit 1042, the dangerous type screening unit 1042 automatically recommends the dangerous type selected by the patient according to one or more dimensions of preset minimum hospital expenditure, minimum patient expenditure, minimum diagnosis and treatment time, minimum insurance consumption, a preset balance ratio of hospital and patient expenditure and the type of the disease, and sends the selected dangerous type to an information matching unit, and the information matching unit is used for establishing a mapping relation between the anti-refusal patient database 101 and the medical insurance drug directory library for a common matching field through the dangerous type.
When the patient has more than one insurance, the patient can be effectively screened for the proper insurance through the dangerous seed identification unit 1041, the dangerous seed screening unit 1042 and the information matching unit according to the screening conditions of the preset minimum hospital expenditure, the minimum patient expenditure, the minimum diagnosis and treatment time, the minimum insurance consumption, the preset balance ratio of the hospital and the patient expenditure, the types of diseases and the like, and the refusal payment is effectively prevented.
As shown in fig. 7, it should be noted that when the number of the specifications of some medicines reaches several pages, the reading time of the doctor is shortened for facilitating reading, so that the doctor can quickly grasp the indication or dosage of the medicine meeting the medical insurance policy. In the technical scheme, the medical insurance policy information prompt module 107 further preferably comprises a drug specification reading unit 1071, a medical insurance information identification unit 1072 and a quick reading unit 1073, wherein the drug specification reading unit 1071 is used for reading the drug specification information in the medical insurance drug directory library, generating an electronic drug specification and sending the electronic drug specification to the medical insurance information identification unit 1072, the medical insurance information identification unit 1072 is used for setting at least one medical insurance identification area in the electronic drug specification, and each medical insurance identification area highlights the text information of taking the drug according to the drug indications or the dosage specified by the specification; the quick reading unit 1073 is configured to extract the medical insurance identification area in the electronic medicine specification, and generate a brief electronic medicine specification mainly based on the medical insurance identification area.
According to the technical scheme, the simplified electronic specification with the identification area can be provided through the medicine specification reading unit 1071, the medical insurance information identification unit 1072 and the quick reading unit 1073, so that a doctor can conveniently and quickly read the medicine specification, know the medicine information and prevent the wrong medicine from being opened.
example 5
the invention also provides a hospital medical insurance cost refusal payment prevention method applying the hospital medical insurance cost refusal payment prevention auxiliary management information system, which comprises the following steps:
S1, fee setting: the method comprises the steps of setting charge types in advance according to medical insurance types, wherein the charge types comprise medical insurance charge types and non-medical insurance charge types, the non-medical insurance charge types are not referred to, and the medical insurance charge types comprise local medical insurance, medical personnel, birth insurance, industrial insurance, student medical insurance, old medical insurance, non-industrial medical insurance, public charge medical treatment and military rest medical insurance.
s2, setting the drug attribute: setting drug attributes, and mapping the drug attributes with the charge types, wherein the drug attributes comprise self-charge attributes and non-self-charge attributes, the non-self-charge attributes comprise non-self-charge drug information read from a medical insurance drug directory library, the self-charge attributes comprise self-charge drug information read from a national basic drug directory library, and the self-charge drug information and the non-self-charge drug information respectively comprise one or more of drug names, drug application symptoms, drug usage and contraindication drug information.
S3, identifying the patient participation insurance category and the dangerous case: and distinguishing whether the patient participates in the insurance and the risk types of the insurance according to the fee classification type of the patient.
S4, setting a prompt by calculating the medication days of the patient:
s4-1, setting the number of medication limit days: determining a defined number of days to administer based on the patient participation category and risk identified in step S3;
S4-2, calculating the actual medication days: automatically calculating the actual medication days of the medicine according to the usage and the dosage of the medicine which is actually prepared by a doctor and is used for a patient;
s4-3, setting prompt information: when the actual number of days for medication calculated in step S4-2 is greater than the limited number of days for medication set in step S4-1, issuing a prompt message of "excessive unprinted dialog" to the doctor;
According to the technical scheme, through real-time statistics of the dosage, a doctor can use the medicine strictly according to the specification of the medicine approved by the national food and drug administration, particularly the medicine is executed according to the indications, the usage, the dosage and the administration route of the specification, the condition that the doctor does not know and master the medicine specification is insufficient, the phenomenon of medication by experience is common, the condition that the patient often has the refusal effect which does not meet the specification and the like is prevented, the doctor-patient relationship is effectively relieved, and the patient's trust level on the patient is improved.
s5, setting reimbursement categories of medicines and diagnosis and treatment items: setting and displaying reimbursement categories of medicines and diagnosis and treatment items for reference of doctors: dividing diagnosis and treatment items and medicines into three kinds of reimbursement items, namely a first kind of items, a second kind of items and a third kind of items according to reimbursement ranges, wherein the first kind of items are medicines and diagnosis and treatment items which are totally brought into the medical insurance reimbursement ranges; the class B item is a medicine and diagnosis and treatment item with self-fee ratio limitation, and part of medicines have the limitation of indications; the class C items are medicine and diagnosis and treatment items which need full self-charge;
When the medical self-fee computer is used, when the medicine with the self-fee is used, the workstation pops up that the item is a medical insurance self-fee item, whether the item is continued or not, and after the item is selected to be 'no', the computer automatically makes a self-fee prescription.
S6, medical insurance reimbursement policy information prompt of medicine and diagnosis and treatment items is set: and prompting the doctor through a prompt box containing prompt information, wherein the prompt information comprises one or more of medicine taking according to medicine indications, medicine taking according to the regulation of a medicine specification and whether the medicine is provided with the indications for post-issuance documents of price.
s7, self-fee agreement verification: when the doctor prescribes the self-fee medicine for the patient, the doctor verifies whether the self-fee protocol exists.
s8, setting the printing of the squares: when doctors provide self-fee medicines and non-self-fee medicines for patients at the same time, the prescriptions are automatically divided and printed into prescription forms of medical insurance medicines and self-fee medicines.
In order to clearly check the self-fee medicines and the non-self-fee medicines, the self-fee medicines and the non-self-fee medicines are printed separately, and when the self-fee medicines are met, a 'item is popped up to indicate whether the item is a medical insurance self-fee item and continues' so as to remind a doctor to inform the patient or family members.
Example 6
Embodiment 6 of the present invention further defines a denial prevention method based on embodiment 5, and the method further includes updating medical insurance reimbursement policy information, and the specific updating method is as follows:
Accessing and acquiring: according to the URL address or the IP address, accessing a server for issuing medical insurance policy information according to a preset time interval, and acquiring issuing time attribute information and page attribute information of an issuing page in the server, wherein the server comprises a local medical insurance information system server 4 and a hospital information system server 3;
Comparison and analysis: comparing the release time attribute information of the release pages acquired at two adjacent times, if the information is not changed, terminating the updating, otherwise, entering the next step; comparing the page attribute information of the issued pages acquired in two adjacent times, comparing the proportion of page character change, if the proportion does not exceed the preset proportion, terminating the updating, otherwise, entering the next step;
establishing a queue: acquiring the release pages with the change of the release time attribute information and the release pages with the change ratio of page characters in the page attribute information exceeding a preset ratio, and establishing a queue for sequencing according to the attribute information, wherein the attribute information comprises one or more of URL (uniform resource locator), IP (Internet protocol) address, server name, medical insurance department and release time;
Fourthly, updating the medical insurance reimbursement policy information: and according to the instruction of a manager, confirming the actually updated release page in the queue, and automatically acquiring and storing the medical insurance reimbursement policy information of the re-edited release page.
The technical scheme realizes the real-time update of medical insurance policy information, and the medical insurance or commodity price part can update the medical insurance policy information in the patient refusal payment prevention database 101 according to the actual situation at any time, thereby providing a basis for later data statistics and reminding
Example 7
The embodiment 7 of the invention further defines an anti-repudiation method on the basis of the embodiment 5, and the method also comprises the following steps of generating a prescription list:
firstly, drugs are inquired in the medical insurance drug directory library and the national basic drug directory library through keywords according to the symptoms of the patients, wherein the keywords comprise one or two combinations of drug names and drug indications;
Secondly, generating a prescription list for the medicines inquired in the first step and the diagnosis and treatment items input by the doctor;
And thirdly, the prescription order generated in the step two is divided to generate a medical insurance medicine prescription order and a self-payment medicine prescription order.
the method is simple in operation, the system operation is based on the patient's treatment flow, medical staff can accurately master and make a professional prescription list only by simple system operation, medicines on the prescription list can be inquired in a medical insurance medicine catalogue library and the national basic medicine catalogue library, and meanwhile, when self-payment medicines or treatment items are designed in the prescription list, the system effectively reminds doctors to inform patients or family members, and the situations of expense refusal or medical expense dispute and the like are prevented from occurring in the later period.
the technical scheme further defines that the method also comprises the following steps: and settling the cost of the medicines or the diagnosis and treatment items on the prescription order, comparing the settled cost with a cost threshold value for reimbursement of medical insurance reimbursement policy information, and if the settled cost exceeds the cost for reimbursement of the medical insurance reimbursement policy information, generating a prompt instruction to prompt a doctor to inform the doctor to a patient or a family member, wherein the cost calculation comprises the following steps:
Calculating the total item cost W of the total amount of medicines and diagnosis and treatment items in the prescription list by the following formula:
W＝n1A1+n2A2+...niAi+m1B1+m2B2+...+mjBj
Wherein, W is the total cost of the project; i is an item of a diagnosis itemthe number of meshes; a. theiThe unit price of the ith diagnosis and treatment item; n isithe number of the ith diagnosis and treatment items is; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjthe number of jth drug;
secondly, according to the medical insurance reimbursement policy information, performing expense reimbursement statistics on the total amount of the medicines and the diagnosis and treatment items marked in the prescription list through the following formula to obtain total reimbursement expense Y:
Y＝(n1×A1×K1)+(n2×A2×K2)+...+(ni×Ai×Ki)+(m1×B1×H1)
+(m2×B2×H2)+...+(mj×Bj×Hj)
Wherein Y is total reimbursement cost; i is the number of items of the diagnosis and treatment items; a. theithe unit price of the ith diagnosis and treatment item; n isiIs the number of the ith diagnosis and treatment item, nithe maximum number value of reimbursement of the diagnosis and treatment items recorded in the medical insurance reimbursement policy information is less than or equal to; kiThe reimbursement proportion of the ith diagnosis and treatment item is obtained; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjthe number of jth medicines is not more than mj, and the maximum number value of reimbursement of the medicines recorded in the medical insurance reimbursement policy information is not more than mj; hjThe reimbursement proportion of the jth drug;
comparing the total project cost W with the total reimbursement cost Y, if the total project cost W is larger than the total reimbursement cost Y, sending a prompt message of 'whether the total project cost exceeds the total reimbursement cost and continues' to a doctor, and if the total project cost W is smaller than or equal to the total reimbursement cost Y, not prompting.
the method clearly explains how the system carries out expense statistics and expense proofreading, thereby improving the accuracy of expense statistics and strictly realizing the accuracy of expense monitoring, so that doctors can accurately inform patients or family members of medical expenses exceeding the reimbursement range, and the condition of expense refusal is avoided.
example 8
Embodiment 8 of the present invention is preferably defined on the basis of embodiment 5, wherein the step of identifying the patient risk species in step S3 further comprises the steps of:
Firstly, a plurality of patient identity data in the local medical insurance information system server 4 is called to be matched with the identity data in the patient transfer prevention database 101 where the current patient is located, and the insurance information of the patient is inquired;
identifying and confirming that the patient is suitable for a certain dangerous type, namely updating or generating the dangerous type attribute information of the patient in the anti-refusal patient database 101; when the patient is identified to be suitable for a plurality of dangerous species, the system automatically pushes out a selection interface, the third step is carried out after the dangerous species is manually selected, and the fourth step is carried out otherwise;
Establishing a mapping relation between the patient refusal payment prevention database 101 and the medical insurance drug catalogue library by taking the dangerous species as a common matching field;
Fourthly, automatically recommending the dangerous species selected by the patient according to one or more dimensions of preset minimum hospital expenditure, minimum patient expenditure, minimum diagnosis and treatment time, minimum insurance consumption, preset balance ratio of hospital and patient expenditure and the types of diseases, and then executing the third step.
the system can provide the patient with the optimal reimbursement risk selection through the method, and the screening condition is one or more of the minimum hospital expenditure, the minimum patient expenditure, the minimum diagnosis and treatment time, the minimum insurance consumption, the preset balance ratio of the hospital and the patient expenditure and the types of diseases.
preferably, the prompting method in step S6 includes:
reading medicine specification information from the medical insurance medicine directory library to generate an electronic medicine specification;
setting at least one medical insurance identification area in the electronic medicine instruction book, wherein each medical insurance identification area highlights character information for taking medicine according to medicine indications or the dosage specified by the instruction book;
Setting a quick reading option, and only providing a brief electronic medicine specification which mainly comprises the medical insurance identification area when the quick reading option is started.
according to the technical scheme, the simplified electronic specification with the identification area can be provided through the medicine specification reading unit 1071, the medical insurance information identification unit 1072 and the quick reading unit 1073, so that a doctor can conveniently and quickly read the medicine specification, know the medicine information and prevent the wrong medicine from being opened.
The present invention is not limited to the above-mentioned preferred embodiments, and any other products in various forms can be obtained by anyone in the light of the present invention, but any changes in the shape or structure thereof, which have the same or similar technical solutions as those of the present application, fall within the protection scope of the present invention.

Claims (6)

1. A hospital medical insurance charge anti-repudiation auxiliary management information system comprises a management server (1) and a user side (2), wherein the user side (2) accesses the management server (1) through a WEB application program, the management server (1) is respectively in communication link with a hospital information system server (3) and a local medical insurance information system server (4), the management server (1) comprises an anti-repudiation patient database (101), and the anti-repudiation patient database (101) is in communication link with a medical insurance drug directory library and a national basic drug directory library;
the management server (1) further comprises a charge setting module (102), a medicine attribute setting module (103), a patient information identification module (104), a medication day prompting module (105), a reimbursement category setting module (106), a medical insurance policy information prompting module (107), a self-payment protocol verification module (108) and a printing module (109), wherein the charge setting module is communicated with the anti-repudiation patient database (101); the anti-denial patient database (101) stores therein patient identity data including patient name, ID number, length of stay, treating physician and type of charge; the fee setting module (102) presets the fee types according to medical insurance types, wherein the fee types comprise medical insurance fee types and non-medical insurance fee types; the drug attribute setting module (103) is used for setting drug attributes, the drug attribute setting module (103) is in communication link with the fee setting module (102), and the drug attributes are mapped with the fee types;
The patient information identification module (104) identifies whether the patient participates in insurance and the risk types of the insurance according to the fee type of the patient and sends the patient to the medication day prompting module (105);
the medication day prompting module (105) comprises a medication day limiting preset unit (1051), an actual medication day calculating unit (1052) and a medication reminding unit (1053), the limited medication day presetting unit (1051) determines the limited medication day according to the patient participation category and the risk category identified by the patient information identification module (104) and sends the limited medication day to the medication reminding unit (1053), the actual medication days calculating unit (1052) automatically calculates the actual medication days of the medicine according to the usage and the dosage of the medicine which is actually prepared by the doctor and is used for the patient, and the medication reminding unit (1053) is used for comparing the actual medication days with the limited medication days, if the actual medication days are more than the limited medication days, the medication reminding unit (1053) generates prompt information of 'no-print dialog box in excess' and sends the prompt information to the user side (2);
the reimbursement type setting module (106) is used for setting reimbursement types of the medicines and the diagnosis and treatment items and displaying the reimbursement types on the user side (2); the medical insurance policy information prompting module (107) generates a prompting frame containing prompting information and sends the prompting frame to the user side (2), wherein the prompting information comprises one or more of medication according to medicine indications, medication according to the regulation of a medicine specification and whether the prompting frame is used for the post-issuance text of the price of the medicine; the self-fee agreement verification module (108) is used for verifying whether a self-fee agreement exists; the printing module (109) is used for distinguishing non-self-fee medicines from self-fee medicines, respectively generating prescription lists of medical insurance medicines and self-fee medicines, and printing the prescription lists at the same time;
the management server (1) further comprises an information updating module (110) communicated with the anti-denial patient database (101), wherein the information updating module (110) comprises an access unit (1101), an acquisition unit (1102), an information analysis unit (1103), a sorting unit (1104) and an information updating unit (1105) which are communicated,
The access unit (1101) respectively accesses the hospital information system server (3) and the local medical insurance information system server (4) according to a URL address or an IP address and according to a preset time interval; the acquisition unit (1102) is used for acquiring the release time attribute information and the page attribute information of the release pages in the hospital information system server (3) and the local medical insurance information system server (4) and sending the release time attribute information and the page attribute information to the information analysis unit (1103); the information analysis unit (1103) is configured to compare issue time attribute information with page attribute information, and if the information changes, send the issue page with the changed issue time attribute information to the sorting unit (1104), where the information analysis unit (1103) is further configured to compare the page attribute information of the issue pages acquired two times in the neighborhood, and if the ratio of page character changes exceeds a preset ratio, send the issue page with the ratio of page character changes exceeding the preset ratio to the sorting unit (1104); the sorting unit (1104) establishes a queue according to attribute information to sort and send the queue to the information updating unit (1105), wherein the attribute information comprises one or more of URL, IP address, server name, medical insurance department and release time; the information updating unit (1105) confirms the actually updated release page in the queue according to the instruction of the administrator, and automatically acquires and stores the medical insurance reimbursement policy information of the re-edited release page in the anti-refusal patient database (101);
The management server (1) also comprises a charge management module (112) communicated with the patient refusal payment prevention database (101), wherein the charge management module (112) comprises a project charge settlement unit (1121), a reimbursement charge settlement unit (1122), a charge comparison unit (1123) and a charge reminding unit (1124),
The item cost settlement unit (1121) is used for carrying out cost statistics on the total number of diagnosis and treatment items and the total number of medicines to obtain an item total cost W, and sending the calculated item total cost W to the cost comparison unit (1123), wherein a calculation formula of the item total cost W is as shown in formula I:
W＝n1A1+n2A2+...+niAi+m1B1+m2B2+...+mjBjFormula 1
wherein, W is the total cost of the project; i is the number of items of the diagnosis and treatment items; a. theiThe unit price of the ith diagnosis and treatment item; n isithe number of the ith diagnosis and treatment items is; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjthe number of jth drug;
The reimbursement expense settlement unit (1122) performs expense reimbursement statistics on the total amount of the medicines and the diagnosis and treatment items marked differently in the prescription order according to the medical insurance medicine catalogue library to obtain reimbursement total expense Y, and sends the calculated reimbursement total expense Y to the expense comparison unit (1123), wherein the calculation formula of the reimbursement total expense Y is as shown in formula II:
Y＝(n1×A1×K1)+(n2×A2×K2)+…+(ni×Ai×Ki)+(m1×B1×H1)+(m2×B2×H2)+…+(mj×Bj×Hj) Formula II
Wherein Y is total reimbursement cost; i is the number of items of the diagnosis and treatment items; a. theiThe unit price of the ith diagnosis and treatment item; n isiIs the number of the ith diagnosis and treatment item, nithe maximum number value of reimbursement of the diagnosis and treatment items recorded in the medical insurance drug catalogue library is less than or equal to; kithe reimbursement proportion of the ith diagnosis and treatment item is obtained; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjnumber of jth drug, mjThe maximum number value of reimbursement of the medicines recorded in the medical insurance medicine catalogue library is less than or equal to; hjThe reimbursement proportion of the jth drug;
The cost comparison unit (1123) compares the calculated total cost W of the project with the total reimbursement cost Y, if the total cost W of the project is greater than the total reimbursement cost Y, the cost comparison unit (1123) sends a reminding instruction to the cost reminding unit (1124), and the cost reminding unit (1124) generates a prompt message for indicating whether the total cost of the project exceeds the total reimbursement cost and continues or not and sends the prompt message to the user end (2);
the management server (1) further comprises a prescription order generation module (111) communicated with the anti-denial patient database (101), wherein the prescription order generation module (111) comprises a query unit (1111), an entry unit (1112) and a distribution unit (1113) which are communicated, the query unit (1111) is used for automatically querying medicines in the medical insurance medicine catalogue library and the national basic medicine catalogue library according to keywords, and sending the queried medicines to the entry unit (1112), and the keywords comprise one or two combinations of medicine names and medicine indications; the entry unit (1112) is used for providing a medicine entry interface, generating a prescription list from the inquired and entered diagnosis and treatment items and sending the prescription list to the dispensing unit (1113); the prescription distribution unit (1113) is used for carrying out prescription distribution processing on the prescription list to generate a medical insurance medicine prescription list and a self-payment medicine prescription list.
2. the hospital medical insurance cost anti-repudiation auxiliary management information system according to claim 1, wherein the patient information identification module (104) comprises a risk category identification unit (1041) communicating with the anti-repudiation patient database (101), a risk category screening unit (1042), and an information matching unit (1043), the risk category identification unit (1041) is used for matching the identity data of the patient in the anti-repudiation patient database (101) with the identity data of the patient stored in the local medical insurance information system server (4), inquiring the insurance information of the patient and sending the insurance information to the risk category screening unit (1042), the risk category screening unit (1042) automatically recommends the risk category for patient selection according to one or more dimensions of the preset minimum hospital expenditure, minimum patient expenditure, minimum diagnosis and treatment time, minimum insurance consumption, preset balance ratio of hospital and patient expenditure, and category of disease, sending the selected dangerous seeds to the information matching unit (1043), wherein the information matching unit (1043) is used for establishing a mapping relation between the patient refusal payment prevention database (101) and the medical insurance drug catalogue library for common matching fields through the dangerous seeds;
The medical insurance policy information prompting module (107) further comprises a drug specification reading unit (1071), a medical insurance information identifying unit (1072) and a quick reading unit (1073) which are communicated with one another, wherein the drug specification reading unit (1071) is used for reading the drug specification information in the medical insurance drug directory library, generating an electronic drug specification and sending the electronic drug specification to the medical insurance information identifying unit (1072), the medical insurance information identifying unit (1072) is used for setting at least one medical insurance identifying area in the electronic drug specification, and each medical insurance identifying area highlights the literal information of taking the drug according to the drug indications or the dosage specified by the specification; the quick reading unit (1073) is used for extracting the medical insurance identification area in the electronic medicine specification and generating a brief electronic medicine specification which mainly comprises the medical insurance identification area.
3. a hospital medical insurance charge rejection method using the hospital medical insurance charge rejection auxiliary management information system according to any one of claims 1 to 2, the method comprising the steps of:
s1, fee setting: setting fee types in advance according to medical insurance types, wherein the fee types comprise medical insurance fee types and non-medical insurance fee types;
s2, setting the drug attribute: setting drug attributes, and mapping the drug attributes with the charge types, wherein the drug attributes comprise self-charge attributes and non-self-charge attributes, the non-self-charge attributes comprise non-self-charge drug information read from a medical insurance drug directory library, the self-charge attributes comprise self-charge drug information read from a national basic drug directory library, and the self-charge drug information and the non-self-charge drug information respectively comprise one or more of drug names, drug application symptoms, drug usage and contraindication drug information;
S3, identifying the patient participation insurance category and the dangerous case: distinguishing whether the patient participates in the insurance and the risk types of the insurance according to the fee classification type of the patient;
s4, setting a prompt by calculating the medication days of the patient:
s4-1, setting the number of medication limit days: determining a defined number of days to administer based on the patient participation category and risk identified in step S3;
S4-2, calculating the actual medication days: automatically calculating the actual medication days of the medicine according to the usage and the dosage of the medicine which is actually prepared by a doctor and is used for a patient;
s4-3, setting prompt information: when the actual number of days for medication calculated in step S4-2 is greater than the limited number of days for medication set in step S4-1, issuing a prompt message of "excessive unprinted dialog" to the doctor;
s5, setting reimbursement categories of medicines and diagnosis and treatment items: setting and displaying reimbursement categories of medicines and diagnosis and treatment items for reference of doctors: dividing diagnosis and treatment items and medicines into three kinds of reimbursement items, namely a first kind of items, a second kind of items and a third kind of items according to reimbursement ranges, wherein the first kind of items are medicines and diagnosis and treatment items which are totally brought into the medical insurance reimbursement ranges; the class B item is a medicine and diagnosis and treatment item with self-fee ratio limitation, and part of medicines have the limitation of indications; the class C items are medicine and diagnosis and treatment items which need full self-charge;
S6, medical insurance reimbursement policy information prompt of medicine and diagnosis and treatment items is set: prompting a doctor through a prompt box containing prompt information, wherein the prompt information comprises one or more of medicine taking according to medicine indications, medicine taking according to the regulation of a medicine specification and whether the medicine is a post-price postissuance letter with the indications;
S7, self-fee agreement verification: when a doctor prescribes self-fee medicines for a patient, verifying whether a self-fee protocol exists;
s8, setting the printing of the squares: when doctors provide self-fee medicines and non-self-fee medicines for patients at the same time, the medicines are automatically divided and printed into a prescription order of medical insurance medicines and a prescription order of self-fee medicines;
The method for preventing the medical insurance cost of the hospital from being refused to pay further comprises the following steps:
s9, updating medical insurance reimbursement policy information, wherein the specific updating method comprises the following steps of S9.1-S9.4:
S9.1 access and get: according to the URL address or the IP address, accessing a server for issuing medical insurance policy information according to a preset time interval, and acquiring issuing time attribute information and page attribute information of an issuing page in the server, wherein the server comprises a local medical insurance information system server (4) and a hospital information system server (3);
S9.2 comparison and analysis: comparing the release time attribute information of the release pages acquired at two adjacent times, if the information is not changed, terminating the updating, otherwise, entering the next step; comparing the page attribute information of the issued pages acquired in two adjacent times, comparing the proportion of page character change, if the proportion does not exceed the preset proportion, terminating the updating, otherwise, entering the next step;
S9.3, establishing a queue: acquiring the release pages with the change of the release time attribute information and the release pages with the change ratio of page characters in the page attribute information exceeding a preset ratio, and establishing a queue for sequencing according to the attribute information, wherein the attribute information comprises one or more of URL (uniform resource locator), IP (Internet protocol) address, server name, medical insurance department and release time;
S9.4, updating medical insurance reimbursement policy information: and according to the instruction of a manager, confirming the actually updated release page in the queue, and automatically acquiring and storing the medical insurance reimbursement policy information of the re-edited release page.
4. the hospital medical insurance cost anti-repudiation method according to claim 3, further comprising:
S10, generating a prescription list, which specifically comprises the following steps of S10.1-S10.1:
s10.1, inquiring medicines in the medical insurance medicine catalogue library and the national basic medicine catalogue library through keywords according to the symptoms of the patients, wherein the keywords comprise one or two combinations of medicine names and medicine indications;
S10.2, generating a prescription list by the medicines inquired in the step S10.1 and the diagnosis and treatment items input by the doctor;
S10.3, the prescription list generated in the step S10.2 is divided to generate a medical insurance medicine prescription list and a self-payment medicine prescription list.
5. The hospital medical insurance cost anti-repudiation method according to claim 4, further comprising:
s11, expense settlement: and (3) settling the cost of the medicine or the diagnosis and treatment item on the prescription order, comparing the settled cost with a cost threshold value for reimbursement of medical insurance reimbursement policy information, and if the settled cost exceeds the cost for reimbursement of the medical insurance reimbursement policy information, generating a prompt instruction for prompting a doctor to inform the patient or family members, wherein the cost settlement comprises the following steps of S11.1-S11.3:
s11.1, calculating the total item cost W of the total amount of medicines and diagnosis and treatment items in the prescription through a formula I:
W＝n1A1+n2A2+...+niAi+m1B1+m2B2+...+mjBjFormula I
wherein, W is the total cost of the project; i is the number of items of the diagnosis and treatment items; a. theithe unit price of the ith diagnosis and treatment item; n isiThe number of the ith diagnosis and treatment items is; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjThe number of jth drug;
s11.2, carrying out expense reimbursement statistics on the total amount of the medicines and the diagnosis and treatment items marked in the prescription bill according to the medical insurance reimbursement policy information by using a formula II:
Y＝(n1×A1×K1)+(n2×A2×K2)+…+(ni×Ai×Ki)+(m1×B1×H1)+(m2×B2×H2)+…+(mj×Bj×Hj) Formula II
Wherein Y is total reimbursement cost; i is the number of items of the diagnosis and treatment items; a. theiThe unit price of the ith diagnosis and treatment item; n isiIs the number of the ith diagnosis and treatment item, niThe maximum number value of reimbursement of the diagnosis and treatment items recorded in the medical insurance reimbursement policy information is less than or equal to; kithe reimbursement proportion of the ith diagnosis and treatment item is obtained; j is the number of the types of the drugs, Bjis the unit price of the jth drug, mjnumber of jth drug, mjthe maximum quantity value of reimbursement of the medicines recorded in the medical insurance reimbursement policy information is less than or equal to; hjThe reimbursement proportion of the jth drug;
s11.3, comparing the total project cost W with the total reimbursement cost Y, if the total project cost W is greater than the total reimbursement cost Y, sending a prompt message of 'whether the total project cost exceeds the total reimbursement cost and continues' to a doctor, and if the total project cost W is less than or equal to the total reimbursement cost Y, not prompting.
6. The method of claim 3, wherein the step of identifying the patient risk category in step S3 further comprises the steps of:
S3.1, calling a plurality of patient identity data in the local medical insurance information system server (4) to be matched with the identity data in the patient transfer prevention database (101) where the current patient is located, and inquiring the insurance participation information of the patient;
S3.2, when the patient is identified and confirmed to be suitable for a certain dangerous species, the attribute information of the dangerous species of the patient in the anti-refusal patient database (101) is updated or generated; when the patient is identified to be suitable for a plurality of dangerous seeds, the system automatically pushes out a selection interface, the step S3.3 is carried out after the dangerous seeds are manually selected, and the step S3.4 is carried out if the dangerous seeds are not manually selected;
s3.3, establishing a mapping relation between the patient refusal payment prevention database (101) and the medical insurance drug catalogue library by taking the dangerous species as a common matching field;
s3.4, automatically recommending which dangerous species are selected by the patient according to one or more dimensions of preset minimum hospital expenditure, minimum patient expenditure, minimum diagnosis and treatment time, minimum insurance consumption, a preset balance ratio of hospital to patient expenditure and the types of diseases, and then executing the step S3.3;
the prompting method in the step S6 includes:
S6.1, reading the information of the medicine specification from the medical insurance medicine catalogue library to generate an electronic medicine specification;
S6.2, at least one medical insurance identification area is arranged in the electronic medicine instruction book, and text information of medicine taking according to medicine indications or medicine taking according to the amount specified by the instruction book is highlighted in each medical insurance identification area;
s6.3, setting a quick reading option, and when the quick reading option is started, only providing a brief electronic medicine specification which mainly comprises the medical insurance identification area.
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