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CN-121998767-A - Medical insurance reimbursement system and reimbursement method

CN121998767ACN 121998767 ACN121998767 ACN 121998767ACN-121998767-A

Abstract

The invention relates to the technical field of data processing, in particular to a medical insurance reimbursement system and reimbursement method. The medical insurance reimbursement system comprises a verification module and a modulation module, wherein the verification module is used for verifying information of medicinal materials, judging whether the medicinal materials are reimbursed to the medical insurance reimbursement system for the first time, and matching the identity of a user with the information of the medicinal materials through the input parameters so as to realize accurate reimbursement of medical insurance and avoid reimbursement medicines from flowing back to the market.

Inventors

  • WANG JINGTAO

Assignees

  • 汪泾涛

Dates

Publication Date
20260508
Application Date
20241102

Claims (10)

  1. 1. A medical insurance reimbursement system is characterized in that a medicinal material tracing code is a unique code corresponding to medicinal materials, the medicinal material tracing code is uploaded to the medical insurance reimbursement system in the reimbursement process, the medical insurance reimbursement system stores medicinal material state attribute codes corresponding to the medicinal materials, the length of a medicinal material state attribute code field corresponding to the medicinal materials enables the medicinal material state attribute code field to have at least two state values, and the medical insurance reimbursement system comprises a second verification module and a modulation module: the second checking module is used for checking the medicinal material information and judging whether the medicinal material corresponding to the medicinal material tracing code uploaded to the medical insurance reimbursement system accords with reimbursement conditions or not; and the modulation module is used for determining reimbursement proportion according to the data uploaded to the medical insurance reimbursement system.
  2. 2. The medical insurance reimbursement system of claim 1, wherein after prescription is prescribed, the medical insurance reimbursement system receives the uploaded prescription information, and the prescription information comprises at least one of information such as a doctor identity attribute code, a medicine category code and the like; the medical material state attribute code has the capability of storing I, II two possible state values, wherein the second checking module reads the medical material state attribute code and sets the medical material state attribute code as I; Defining that the medicinal material state attribute codes read at different time nodes are respectively a first medicinal material state attribute code, a second medicinal material state attribute code and the like according to different time nodes read by the medicinal material state attribute codes; And after the verification of the second verification module, the medical insurance reimbursement system calls the modulation module, and reimbursement parameter return values are obtained according to the prescription information.
  3. 3. The medical insurance reimbursement system according to claim 2, wherein the medical insurance reimbursement system has reimbursement state codes corresponding to prescriptions (hereinafter referred to as prescription reimbursement state codes), the length of a field of the prescription reimbursement state codes is more than or equal to one bit, so that the field of the prescription reimbursement state codes has at least two state values, and the prescription reimbursement state codes are divided into a first prescription reimbursement state code, a second prescription reimbursement state code and the like according to different acquisition time nodes of the prescription reimbursement state codes, wherein the prescription reimbursement state codes have the capability of storing two state values, i and ii; The medical insurance reimbursement system further comprises a first verification module, wherein the first verification module is used for verifying the prescription information and judging whether the prescription reimburses the medicinal materials according to the prescription reimbursement state code, the identity attribute code of the doctor and the medicinal material class code, the first verification module is called by the medical insurance reimbursement system after the prescription is uploaded, and the second verification module is called by the medical insurance reimbursement system after the medicinal materials are distributed.
  4. 4. The medical insurance reimbursement system according to claim 2 or 3, wherein the medical insurance reimbursement system further comprises a third verification module, wherein the medical insurance reimbursement system receives a medical institution code uploaded by a medical institution in a warehouse (namely, a warehouse institution code), a medical institution code uploaded by a medicine dispensing process (namely, a medicine dispensing institution code) and prescription information, the medical insurance reimbursement system calls the third verification module to obtain the warehouse institution code and the medicine dispensing institution code, compares the warehouse institution code with the medicine dispensing institution code, and terminates reimbursement if the warehouse institution code is inconsistent with the medicine dispensing institution code, and performs the next reimbursement flow if the warehouse institution code is consistent with the medicine dispensing institution code; The third checking module is called by the medical insurance reimbursement system after the medical consultant uploads the medicine tracing code, and the identity attribute code of the medical consultant is uploaded to the medical insurance reimbursement system by the medical institution when the prescription is prescribed.
  5. 5. The medical insurance reimbursement system according to claim 2, wherein the medical insurance reimbursement system uploads a medicine traceability code to complete reimbursement, and the medical insurance reimbursement system invokes the second checking module and the modulation module in the following manner: s4.2, calling a second checking module by the medical insurance reimbursement system to obtain a second medicinal material state attribute code; S4.2.1, terminating reimbursement if the second medicinal material state attribute code is I, and calling a modulation module if the second medicinal material state attribute code is not I, and determining reimbursement proportion according to the identity attribute code of the doctor and the medicinal material category code to finish reimbursement.
  6. 6. The medical insurance reimbursement system according to claim 3, wherein the medical insurance reimbursement system uploads a medicine tracing code to complete reimbursement, and the medical insurance reimbursement system calls the first checking module, the second checking module and the modulating module in the following manner: S2.1, judging whether the prescription has reimbursement medicinal materials or not by a first verification module after the prescription information is uploaded; S2.2, the medical insurance reimbursement system reads a prescription reimbursement state code, if the prescription reimbursement state code is i, the reimbursement is terminated, if the prescription reimbursement state code is not i and a reimbursement person accords with reimbursement conditions, the prescription reimbursement state code is set as iii or the original prescription reimbursement state code is maintained, and if the reimbursement person does not accord with reimbursement conditions, the prescription reimbursement state code is set as i, and the reimbursement is terminated; s4.2, calling a second checking module by the medical insurance reimbursement system to obtain a second medicinal material state attribute code; S4.2.1 terminating reimbursement if the second medicinal material state attribute code is I, and calling a modulation module if the second medicinal material state attribute code is not I and the prescription reimbursement state code is not I, and determining reimbursement proportion according to the identity attribute code of the doctor and the medicinal material type code to finish reimbursement.
  7. 7. The medical insurance reimbursement system according to claim 4, wherein the medical insurance reimbursement system uploads a medicine tracing code to complete reimbursement, and the medical insurance reimbursement system calls the third checking module, the second checking module and the modulating module in the following manner: uploading a warehousing mechanism code and a medicinal material tracing code to the medical insurance reimbursement system by a medical institution when medicinal materials are warehoused; generating a corresponding prescription unique code when a doctor issues a prescription, wherein the prescription information comprises the prescription unique code; s3, uploading a code of a dispensing mechanism and a unique code corresponding to the prescription when dispensing in a pharmacy; S4.2, after the doctor uploads the medicine tracing code, the medical insurance reimbursement system calls a third verification module, the third verification module reads a warehousing mechanism code according to the medicine tracing code, reads a dispensing mechanism code according to a prescription unique code, and terminates reimbursement if the warehousing mechanism code is inconsistent with the dispensing mechanism code; s4.3, the medical insurance reimbursement system calls a second check module to obtain a second medicinal material state attribute code, and the medicinal material state attribute code is set as I; S4.3.1 terminating medical insurance reimbursement if the second medicinal material state attribute code is I, calling a modulation module to finish reimbursement if the second medicinal material state attribute code is not I, and binding modification of the medicinal material state attribute code to the I state and reimbursement operation into a transaction when reimbursement conditions are met.
  8. 8. A method of reimbursement for medical insurance using the medical insurance reimbursement system of claim 5, wherein the reimbursement steps are: step 1, a doctor issues a prescription and uploads prescription information; Step 2, the doctor pays normally; step 3, drug delivery in pharmacy; step 4, the doctor scans the medicine tracing code to finish reimbursement: step 4.1, scanning by a doctor and uploading a medicine tracing code; Step 4.2, calling a second checking module by the medical insurance reimbursement system; and 4.2.1, if the second medicinal material state attribute codes are not I, calling a modulation module.
  9. 9. A method of reimbursement for medical insurance using the medical insurance reimbursement system of claim 6, wherein the reimbursement steps are: step 1, a doctor issues a prescription and uploads prescription information; step 2, calling a first verification module by a medical insurance reimbursement system; Step 4, the doctor scans the medicine tracing code to finish reimbursement: step 4.1, scanning by a doctor and uploading a medicine tracing code; step 4.2, the medical insurance reimbursement system calls a second checking module; And 4.2.1, if the state attribute code of the second medicinal material is not I and the prescription reimbursement state code is not I, calling a modulation module.
  10. 10. A method of reimbursement for medical insurance using the medical insurance reimbursement system of claim 7, wherein the reimbursement steps are: step 0, a medical institution uploads a medical institution code and a medical traceability code to the medical insurance reimbursement system when the medical institution stores the medical institution, wherein the first medical condition attribute code of the medical traceability code is II; Step 1, a doctor issues a prescription and uploads prescription information containing a unique prescription code: step 2, paying by the doctor; step 3, drug delivery in pharmacy; step 4, the doctor scans the medicine tracing code: step 4.1, scanning by a doctor and uploading a medicine tracing code; step 4.2, the medical insurance reimbursement system calls a third verification module; And 4.3, calling a second checking module by the medical insurance reimbursement system.

Description

Medical insurance reimbursement system and reimbursement method Technical Field The invention relates to the technical field of data processing and analysis, in particular to a medical insurance reimbursement system and reimbursement method. Background With the increase of the reimbursement proportion of medical insurance, a plurality of intermediate merchants utilize the medical insurance accounts of masses to brush high-price medicines at low price in an A medical store (hospital), and transfer hands to sell the high-price medicines to a B medical store (hospital) at normal price, so that high price difference is earned. The current common solution is to put an end to this situation through a traceability system. The existing traceability system realizes medicinal material traceability by uploading data of the prescription, and the mode can bring greater pressure to the huge-pressure medicine dispensing pharmacy in the peak period of centralized treatment of the patient, which is not beneficial to the treatment of the patient in the hospital. If the code is scanned by the doctor and uploaded by the doctor, reimbursement is realized, because the reimbursement proportion of different doctor in different medicinal materials is different, the actual reimbursement condition is complex, and the realization difficulty is large: for example, for a patient taking medicine for a long time for chronic disease, targeted medicinal materials A1 and A2 have a higher reimbursement ratio, while for other medicinal materials, reimbursement ratio is lower, and because the patient is not professional, uploading reimbursement information for medical insurance by the patient is more difficult. Disclosure of Invention The invention aims to solve the problems that ① medical insurance medicinal materials are returned to the market again and the medical insurance foundation is emptied, and ② reimburses different medical insurance medicinal materials for different patients. In order to solve the problems, and simultaneously to avoid excessive pressure of drug administration and improve the medical experience of a doctor, the invention is realized by the following technical means: A medical insurance reimbursement system comprising two verification modules and a modulation module: the medical insurance reimbursement system is characterized by comprising a medical insurance reimbursement system, a medical insurance reimbursement system and a control system, wherein the medical insurance reimbursement system is used for uploading a medical insurance reimbursement code to the medical insurance reimbursement system, the medical insurance reimbursement system stores medical insurance state attribute codes corresponding to the medical insurance, the medical insurance reimbursement system has a medical insurance state attribute code corresponding to the medical insurance, and the medical insurance state attribute code field length corresponding to the medical insurance reimbursement system enables the medical insurance reimbursement system to at least have the capability of representing two state values, and the medical insurance reimbursement system comprises two verification modules and a modulation module: And the first checking module is used for checking the identity of the user and the information of the prescription medicinal materials, and judging whether the prescription has reimbursement medicinal materials according to the checking result after the checking is finished. And the second checking module is used for checking the information of the medicinal materials and judging whether the medicinal materials corresponding to the medicinal material tracing code meet the reimbursement condition or not, inquiring the medicinal material data according to the medicinal material tracing code, and reading the medicinal material state attribute code corresponding to the medicinal material tracing code after the inquiry is finished. And the modulation module is used for determining reimbursement proportion according to the data uploaded to the medical insurance reimbursement system. It is noted that the first checking module is an unnecessary module. Drawings FIG. 1A flow chart corresponding to embodiment 1 FIG. 2A flow chart corresponding to embodiment 2 FIG. 3A flow chart corresponding to embodiment 3 Detailed Description For the purpose of more convenient explanation, technical solutions and advantages of the present invention, the technical solutions of the present invention will be clearly and completely described below with reference to the embodiments and drawings of the present invention. It will be apparent that the described embodiments are some, but not all, embodiments of the invention. All other embodiments, which can be made by a person skilled in the art without making any inventive effort, are intended to be within the scope of the present invention. It should be noted that the definitions in the present application are onl