JP7085167B2 - Insurance payment support system, program and recording medium - Google Patents

Description

The present invention is based on a medical statement (free of charge) that describes specific details such as examinations, treatments, medications, and medical expenses, which are obligatory to be issued at hospitals and dispensing pharmacies. It relates to insurance payment support systems, programs and recording media that are derived and determine whether or not insurance payments can be made.

Insurance such as medical insurance and accident insurance provides insurance (special contract) to prepare for financial risks in the event of illness or injury. At the insurance company, the person in charge of certification (judgment of insurance payment) comprehensively considers the contents described in the (paper) information such as the medical certificate and the terms and conditions prepared in advance by the insurance company, and decides whether or not to pay. Is going. Specifically, for the injury / illness name and surgery name, etc. declared by the contractor (patient) on the "insurance claim", etc., confirm the injury / illness name, surgery name, etc. on the medical certificate issued by the doctor. Insurance money is paid in light of the terms and conditions at the time of contract.

Insurance companies often require the contractor (patient) to submit a medical certificate as evidence regarding the name of the injury or illness or the name of the surgery in order to pay the insurance money according to the name of the injury or illness or the name of the surgery. However, the medical certificate is issued by a medical institution, and after the contractor (patient) requests the medical institution to create it, the doctor (medical worker) will create it. It takes a certain amount of time. Further, in order to receive the medical certificate, the contractor (patient) needs to go to the medical institution again, and there is a problem that it takes time from the request for preparing the medical certificate to the receipt of the medical certificate.

Conventionally, in order to reduce the burden on insurance benefit claimants (contractors, etc.), a benefit payment system that makes it easy for claimants to apply for insurance benefits has been proposed (Patent Document 1). In the benefit payment system described in Patent Document 1, the medical institution provides the benefit certification request information necessary for benefit payment such as the name, address, injury / illness name, operation date, hospitalization or hospital visit period of the claimant (contractor). The medical institution receives the benefit certification request information, refers to the medical information database, and inputs the necessary items for certification. The insurance company receives the information required for proof and the benefit proof information approved by the attending physician, and decides the benefits.

Japanese Unexamined Patent Publication No. 2002-259557

However, the benefit payment system described in Patent Document 1 can reduce the burden of the claimant (contractor, etc.) going to the medical institution to request and receive the medical certificate, but it is prepared by the medical institution. There is still a problem that it takes time for a doctor (medical worker) to create proof information (documents) such as a medical certificate after requesting.

In addition, the preparation of a medical certificate is a task other than medical practice such as diagnosis and treatment for a doctor (medical worker), and is performed between medical treatments. From the aspect of "work style reform", it is necessary to reduce the work of creating medical certificates.

In addition, the policyholder pays the medical certificate preparation fee, but even if the medical certificate is submitted to the insurance company, it may not be covered by the insurance claim as a result of the certification, and the claim procedure is timely and economical. May also suffer disadvantages.

Furthermore, regarding the certification work of the insurance company, the person in charge of certification of the insurance company makes a personal judgment. Therefore, depending on the number of years of work experience and the amount of knowledge of the person in charge of certification, there is a problem that different certifications may be made despite the same etiology and pathology due to the difference in interpretation of the contents described in the medical certificate. rice field.

Therefore, the present invention solves the above-mentioned problems of the prior art, and an object of the present invention is to derive a corresponding injury / illness name based on a medical statement prepared by a medical institution at the time of consultation, and to obtain insurance money. The purpose is to provide an insurance payment support system, a program, and a recording medium for determining whether or not payment is possible.

According to the present invention, the insurance payment support system is based on a medical statement that describes specific contents such as examinations, treatments, medications, and medical expenses, which are required to be issued at the counter of hospitals and dispensing pharmacies. It is an insurance payment support system that determines whether or not insurance money can be paid, and the Ministry of Health, Labor and Welfare refers to the text data of the medical treatment details described in the medical treatment statement by referring to the medical treatment statement dictionary master created in advance. Refer to the medical practice data creation means for creating medical practice data by assigning the medical practice code or drug code specified in the above, and the indication disease name master and disease name extraction rule master created in advance from the medical practice practice data, and the corresponding adaptation. At least the accuracy of the indication disease name data is based on the indication disease name data creation means for creating the indication disease name data by adding the disease name, the disease name code and its accuracy information, and the disease name derivation rule created in advance from the indication disease name data. The first payment decision to determine whether or not a person is eligible for insurance payment by referring to the insurance policy / special contract master based on the disease name derivation method for deriving a high disease name and the disease name derived by the disease name derivation method. It has the means.

The contractor can claim the insurance without a medical certificate by deriving the name of the relevant injury or illness based on the medical statement prepared free of charge by the medical institution at the time of consultation and deciding whether or not to pay the insurance. Therefore, the fee for creating a medical certificate can be saved. In addition, since a medical certificate is not required, it is possible to reduce the work and time required to create a medical certificate at a medical institution (doctor, etc.). In addition, the certified person in charge of the insurance company does not require human judgment, which reduces the burden of paperwork and makes it possible to obtain more accurate judgment results, realizing appropriate and early payment to policyholders. be able to.

In this specification, the medical statement describes the medical treatment contents, tests, treatments, prescription drugs, etc. issued to the patient free of charge by the medical institution at the time of receiving a medical examination (that is, when the patient pays the treatment fee). It is a document.

In addition, surgery / treatment data creation means that extracts information on surgery / treatment from medical practice data, assigns a code (K code, etc.) that classifies medical practice specified by the Ministry of Health, Labor and Welfare, and creates surgery / treatment data. It is preferable to further provide a second payment determination means for determining whether or not the insurance is eligible for payment by referring to the insurance policy / special contract master based on the surgery / procedure data. This makes it possible to determine whether or not the medical statement is eligible for payment of insurance money if there is content related to surgery / treatment and if there is a special contract for insurance related to it.

Further, it is preferable that the first payment determination means and the authorization result data creation means for creating the insurance claim payment approval / disapproval result information determined by the second payment determination means as the authorization result data are further provided. This makes it possible to notify the contractor of the certification result via the communication network.

Further, it is preferable to further provide a data conversion means for converting the character string of the medical practice content described in the medical statement into data as text data. This makes it possible to easily form text data from a paper medical statement.

Further, when assigning a medical practice code or a drug code to text data, a dictionary update means for adding and correcting text data that does not match the medical statement dictionary master and cannot be assigned a code is further provided. Is preferable. As a result, the medical statement dictionary master can be constantly updated and the matching rate can be improved.

According to the present invention, the insurance payment support program is based on a medical statement that describes specific contents such as examination, treatment, medication, and medical expenses, which are required to be issued at the counter of a hospital or a dispensing pharmacy. It is an insurance claim payment support program that determines whether or not to pay insurance claims, and a computer is used with reference to a pre-created medical statement dictionary master for text data of medical practice content described in the medical statement. Refer to the medical practice data creation means for creating medical practice data by assigning the medical practice code or drug code specified by the Ministry of Health, Labor and Welfare, and the adaptive disease name master and disease name extraction rule master created in advance from the medical practice data. Of the indication disease name data, based on the indication disease name data creation means for creating the indication disease name data by adding the corresponding indication disease name, disease name code and its accuracy information, and the disease name derivation rule created in advance from the indication disease name data. Based on the disease name derivation means that derives the disease name with at least high accuracy and the disease name derived by the disease name derivation means, the insurance policy / special contract master is referred to to determine whether or not the insurance is eligible for payment. It is characterized by functioning as a means of determining payment.

In addition, the computer extracts information on surgery / treatment from medical practice data, assigns a code (K code, etc.) that classifies medical practice specified by the Ministry of Health, Labor and Welfare, and creates surgery / treatment data. It is preferable to make it function as a second payment judgment means for judging whether or not the insurance is eligible for payment by referring to the insurance contract / special contract master based on the means and the surgery / treatment data.

Further, it is preferable to make the computer function as a certification result data creation means for creating the insurance claim payment approval / disapproval result information determined by the first payment determination means and the second payment determination means as the certification result data.

Further, it is preferable to make the computer function as a data conversion means for converting the character string of the medical practice content described in the medical statement into data as text data.

Further, when the computer assigns the medical practice code or the drug code to the text data, the dictionary update means for adding and correcting the text data that does not match the medical statement dictionary master and the code cannot be assigned to the medical statement dictionary master. It is preferable to make it function as.

According to the present invention, the recording medium is a computer-readable recording medium characterized in that the insurance payment support program is recorded.

According to the present invention, the contractor can obtain a medical certificate without a medical certificate by deriving the name of the corresponding injury or illness based on the medical statement prepared free of charge by the medical institution at the time of consultation and determining whether or not the insurance money can be paid. Insurance claims can be made, and the fee for preparing a medical certificate can be saved. In addition, since a medical certificate is not required, it is possible to reduce the work and time required to create a medical certificate at a medical institution (doctor, etc.). In addition, the certified person in charge of the insurance company does not require human judgment, which reduces the burden of paperwork and makes it possible to obtain more accurate judgment results, realizing appropriate and early payment to policyholders. be able to.

In addition, when claiming insurance money, there is no need for time to request the creation of a medical certificate or receive the medical certificate. For doctors (medical professionals), the time to prepare a medical certificate will be reduced, which will be beneficial in terms of "work style reform". In addition, for insurance companies that pay insurance claims, the work of attaching medical certificates is reduced, which shortens the period from the policyholder's claim for insurance claims to the payment of insurance claims. By shortening the time from claim to payment, the service to policyholders will be improved.

In addition, regarding the certification work, the homogeneity of the certification content will be improved for the same etiology and pathophysiology (examination, examination, treatment) that may result from misinterpretation depending on the number of years of work experience and the amount of knowledge of the person in charge. Therefore, the work of determining whether or not to pay the insurance money and the amount of insurance will be streamlined, and the re-examination work will be reduced.

It is a figure which shows schematic application example of the insurance money payment support system in one Embodiment of this invention. It is a figure which shows the structure of the insurance money payment support system shown in FIG. 1 schematically. It is a flowchart which shows an example of the processing procedure in an insurance money payment support system. It is a figure which shows the example which creates the text data of the medical treatment action content described in the medical treatment statement in the insurance money payment support system. It is a figure which shows the example which creates the medical practice data in the insurance money payment support system. It is a figure which shows the example which extracts the indication disease name in the insurance money payment support system. It is a figure which shows the example of the method of extracting the indication disease name in the insurance money payment support system. It is a figure which shows schematic example of the derivation of a disease name and the judgment | judgment of an insurance money payment in an insurance money payment support system. It is a figure which shows the example of the method of deriving the disease name in the insurance money payment support system. It is a figure which shows outline example of the code assignment to the operation / treatment information and the judgment example of the operation insurance payment in the insurance money payment support system. It is a figure which shows schematic the generation and display example of the authorization result data in the insurance money payment support system. It is a figure which shows the display example of the sub screen of the authorization result data in the insurance money payment support system, (A) the derivation name all list, (B) medical care details unmatched information.

Hereinafter, embodiments of the insurance claim payment support system, the program, and the recording medium according to the present invention will be described with reference to the drawings.

FIG. 1 shows an application example of the insurance claim payment support system 100 of the present invention, and FIG. 2 schematically shows the configuration of the insurance claim payment support system 100.

As shown in FIG. 1, the insurance money payment support system 100 communicates between a contractor (user or patient) terminal 101, an insurance company (insurance institution) terminal 102, a medical practice master 103, and a drug master 104. It is connected so that it can communicate via N. The medical practice master 103 and the drug master 104 are databases managed by the social insurance medical fee payment fund. The medical practice master 103 includes information such as a medical practice code, a classification, and a medical practice name. The drug master 104 includes information such as a drug code and a drug name.

Further, as shown in FIG. 2, the insurance money payment support system 100 includes a receiving means 10, an input means 20, a recording means 30, a processing means 40, a control means 50, a display means 60, and a transmission means 70. And, it is composed of a computer equipped with an output means 80, and is configured to derive the corresponding injury / illness name based on the medical statement issued by the medical institution submitted by the contractor and determine whether or not the insurance money can be paid. Has been done.

The receiving means 10 is configured to receive necessary information such as a medical statement transmitted from the contractor terminal 101 via the insurance company terminal 102 via a communication network N such as the Internet. The information acquired by the receiving means 10 is stored in the recording means 30.

The input means 20 includes a keyboard, a touch panel, or the like, and is for inputting a processing operation start command, necessary correction information, and the like. In the present embodiment, the insurance company terminal 102 also functions as an input means. In addition, read and input the information stored by the reading device of the medium such as FD (floppy (registered trademark) disk), CDROM (compact disk), MO (magneto-optical disk), DVD (digital video disk) as an input means. You may use it for.

The recording means 30 is mainly composed of a hard disk (HDD) and RAM and ROM memories. In addition to the control program, the recording means 30 includes a program 30a for deriving the corresponding injury / illness name based on the medical statement and determining whether or not to pay the insurance money, the medical statement dictionary master 31, and the indication disease name master 32. , Disease name extraction rule master 33, disease name derivation rule master 34, contract / special contract master 35, surgery / treatment master 36, combination master 37, accuracy master 38, and the like are stored. In addition, the created medical statement text data 39a, contractor data 39b, case data 39c, medical practice data 39d formed in the processing process, indication disease name data 39e, disease name derivation data 39f, injury / disease corresponding data 39g, surgery / treatment data. Information such as 39h, operation / treatment applicable data 39i, and certification result data 39j is stored. The recording means 30 also stores a correction master (not shown) for updating the medical detail dictionary master 31.

The program 30a causes the computer to function as a recording means 30 and a data processing means 40. The medical statement dictionary master 31 and the indication disease name master 32 are preconfigured based on the medical practice master 103 and the drug master 104 of the social insurance medical fee payment fund. In the medical practice master 103, the code corresponding to the standard treatment practice name is possessed. In the drug master 104, the code corresponding to the drug is possessed. The disease name extraction rule master 33 is composed of predetermined disease name extraction criteria / methods. The disease name derivation rule master 34 is composed of predetermined disease name derivation criteria / methods. The contract / special contract master 35 is a master table created by an insurance company and composed of items such as an insurance contract code, an insurance item name, an insurance product name, and coverage. The surgery / treatment master 36 has a code (K code, etc.) for classifying medical practices specified by the Ministry of Health, Labor and Welfare corresponding to the surgery name. The combination master 37 is a database relating to a combination in which the name of an injury or illness can be specified by combining the "action for the purpose of diagnosing the disease name" and the "action for the purpose of treatment" (medical treatment). The accuracy master 38 is a database regarding the accuracy of injury / illness names related to "actions for the purpose of treatment" (medical treatment actions).

The processing means 40 includes a data conversion means 41 that converts a character string of the treatment action content into data as text data, a medical practice data creation means 42, an indication disease name data creation means 43, a disease name derivation means 44, and a first payment. It includes a determination means 45, an operation / procedure data creation means 46, a second payment determination means 47, a certification result data creation means 48, and a dictionary update means 49.

The data conversion means 41 is configured to convert the character string of the treatment action content described for each medical treatment category in the medical treatment statement into data as text data. The medical practice data creating means 42 refers to the medical statement dictionary master 31 created in advance, and refers to the text data (medical statement text data 39a) of the medical practice content described in the medical statement, by the Ministry of Health, Labor and Welfare. It is configured to create medical practice data 39d by assigning a predetermined medical practice code or drug code. The adaptive disease name data creating means 43 refers to the adaptive disease name master 32 created in advance from the medical practice data 39d, assigns information on the corresponding adaptive disease name (injury / disease name), disease name code, and its accuracy, and assigns information on the indication disease name data 39e. Is configured to create. The disease name derivation means 44 is configured to derive at least a highly accurate disease name from the indication disease name data 39e based on a disease name derivation rule created in advance from the indication disease name data 39e, and create the disease name derivation data 39f. There is. The first payment determination means 45 refers to the insurance policy / special contract master 35 based on the injury / illness name derived by the disease name derivation means 44, and determines whether or not the insurance is eligible for payment. It is configured. The surgery / treatment data creating means 46 extracts information on surgery / treatment from the medical practice data 39d, assigns a code (K code, etc.) for classifying medical practice specified by the Ministry of Health, Labor and Welfare, and creates surgery / treatment data 39h. It is configured to do. The second payment determination means 47 is configured to determine whether or not the insurance money is to be paid by referring to the insurance policy / special contract master 35 based on the surgery / procedure data 39h. The certification result data creating means 48 is configured to create the approval result information as the certification result data 39j, which is the result information on whether or not the insurance money can be paid, which is determined by the first payment determining means 45 and the second payment determining means 47. When the medical practice code or the drug code is assigned to the text data of the medical statement, the dictionary updating means 49 transfers the text data to the medical statement dictionary master 31 that does not match the medical statement dictionary master 31 and cannot be assigned the code. It is configured to add and correct.

The control means 50 includes a CPU (Central Processing Unit) and is for controlling the overall operation of the insurance claim payment support system 100.

The display means 60 includes a CRT (Cathode-Ray Tube), an LCD (Liquid Crystal Display), an EL display (Electroluminescence Display), etc., and includes a medical statement, data, a message composed of characters or images, certification result data 39j, and the like. Is configured to display. The output means 80 is configured to output the created certification result data 39j to a display means 60, a recording means 30, a transmission means 70, or a printer and print it on paper or the like.

In FIG. 1, the communication network N can be realized by various networks such as the Internet or a LAN (local area network). Further, since the communication line is encrypted by a technique such as SSL or VPN, the possibility of leakage / interception is extremely low.

In the policyholder terminal 101, in order to make an insurance claim, the policyholder information (contractor identification information such as name and telephone number) is input and transmitted to the insurance company terminal 102. Further, the image data of the medical statement is transmitted from the contractor terminal 101 to the insurance company person in charge terminal 102 via the communication network N.

In the insurance company terminal 102, case information is input based on the contractor information and the medical treatment statement sent from the contractor terminal 101, and the image data of the medical treatment statement is converted into text data to create text data. .. The work of converting the image data of the medical statement into text data or the work of inputting the text data based on the contents of the medical statement may be performed by the insurance claim payment support system 100.

In the insurance money payment support system 100, the processing work is started by receiving the certification processing instruction from the insurance company terminal 102.

Hereinafter, a processing procedure for determining whether or not insurance claims can be paid based on the information in the medical statement using the insurance claim payment support system 100 will be described with reference to FIGS. 3 to 12. FIG. 3 shows an example of the processing process of the insurance claim payment support system 100.

As shown in FIG. 3, the process of the insurance claim payment support system 100 first logs in from the insurance company terminal 102, and then registers / changes the case information based on the insurance claim information transmitted from the policyholder terminal. (Step S10). Next, the image data of the medical statement is converted into text data, and the text data is created (step S20). FIG. 4 shows an example of the image data of the medical treatment statement and the created medical treatment statement text data 39a.

Next, the medical treatment detail dictionary master 31 is referred to to the medical treatment detail text data 39a, and the medical treatment behavior code and the drug code (pharmaceutical code) based on the medical treatment practice master 103 and the drug master 104 are assigned, and the medical treatment practice data 39d is obtained. Create and save (step S30). Here, the dictionary update process is performed in step S31 for the medical practice unmatched data for which the code could not be assigned, and new text data is added to the medical care statement dictionary master 31. FIG. 5 shows an example of medical practice data 39d created by assigning a medical practice code and a drug code to medical detail text data 39a. In addition, FIG. 5 also shows an example of medical practice unmatched data. The correction master is referred to for these medical practice unmatched data, and the standard medical practice name based on the medical practice master 103 and the drug master 104 is added to the medical statement dictionary master 31.

Next, based on the medical practice data 39d, the indication disease name (injury / disease name) is extracted with reference to the indication disease name master 32 and the disease name extraction rule master 33, the indication disease name and the disease name code are given, and the indication disease name data 39e is created. (Step S40). FIG. 6 shows an example of the indication disease name data 39e created from the medical practice data 39d. As shown in FIG. 6, the indication disease name data 39e includes medical details, medical practice (pharmaceutical product) code, disease name code, injury / disease name (indication disease name name), ICD10 code, and accuracy information.

In this step S40, as shown in FIG. 7, first, in step S41, the medical practice data 39d including the drug data is distributed to the medical care categories, and further, for the purpose of "disease name diagnosis" such as "examination" and "imaging diagnosis". It is divided into "acts for the purpose of treatment" such as "surgery", "medicines", "treatment" and "others". Next, in step S42, a combination that can identify the injury / illness name by collating with the combination master 37 prepared in advance for the “action for the purpose of diagnosing the disease name” and combining with the “action for the purpose of treatment” is provided. Extract. Next, in step S43, the “action for the purpose of treatment” is collated with the accuracy master 38 and sorted according to the specific accuracy of the injury / illness name. Also, data for which accuracy has not been set is excluded. Next, in step S44, the data to be combined in step S42 and the data whose accuracy is set in step S43 collate with the indication disease name master 32, and the indication disease name code and name and the ICD10 code are extracted and the indication disease name extraction data. Save as.

Next, the disease name is derived from the indication disease name data 39e with reference to the disease name derivation rule master 34, and the disease name derivation data 39f is created (step S50). Here, the test information performed when the doctor makes a diagnosis and the treatment content (treatment, medication, etc.) after the diagnosis are comprehensively judged while considering the accuracy, and the disease name is derived. When deriving the disease name, the disease name code set by the Ministry of Health, Labor and Welfare and the international disease classification code (IDC-10, etc.) are assigned, and the disease name derivation data 39f is extracted. In addition, the obtained disease name derivation data 39f is stored.

Next, based on the disease name derivation data 39f, the contract / special contract master 35 is referred to, it is determined whether or not the derived disease name is subject to insurance payment, and the result is created and saved as the injury / illness corresponding data 39g (). Step S60).

FIG. 8 shows an example of the disease name derivation data 39f and the injury / disease corresponding data 39g. As shown in FIG. 8, the disease name derivation data 39f includes information such as a disease name code, an injury / disease name, and an ICD10 code. The injury / illness applicable data 39g includes information such as the insurance product name, the contract / special contract ICD10 code, the contract target disease name, and the judgment of payment applicable (for example, “×” or “〇”).

In step S50 above, as shown in FIG. 9, when the disease name derivation rule master 34 is referred to for the indication disease name data 39e and the disease name derivation data 39f is created, the “combination target” and “determination” in the figure are made. If there is data for a group consisting of "", only the name of the target injury or illness will be the derivation result. If there is data in a group consisting of "accuracy: high", "accuracy: medium", and "accuracy: low" in the figure, sort by accuracy in order of the number of extractions and the number of times. The number of cases specified in advance is used as the derivation result. Here, filing of the extracted injury / illness name is carried out based on the derivation rule set in advance by the insurance company's contract / special contract information.

Next, it is determined whether or not the text data 39a of the medical statement has contents related to surgery / treatment (step S70). Here, if it is determined that the text data 39a of the medical statement has contents related to surgery / treatment (in the case of Yes), the process proceeds to step S80. On the other hand, if it is determined that there is no content related to surgery / treatment (No), the process proceeds to step S100.

Next, in step S80, the surgery / treatment master 36 is referred to based on the medical practice data 39d, the surgery / treatment information is extracted, a code is assigned, and the surgery / treatment data 39h is created.

Next, based on the surgery / treatment data 39h, it is determined whether or not the extracted surgery / treatment content is subject to insurance payment by referring to the terms / conditions / special contract master 35, and the result is the surgery / treatment corresponding data 39i. Create and save as (step S90).

Next, the certification result data 39j is generated and stored based on the injury / illness corresponding data 39g and the surgery / treatment corresponding data 39i obtained in steps S60 and S90 (step S100). FIG. 11 shows an image of generating and storing the certification result data 39j based on the injury / illness corresponding data 39g and the surgery / treatment corresponding data 39i. If it is determined in step S70 that the text data 39a of the medical statement has no content related to surgery / treatment (No), the certification result data is based only on the injury / illness corresponding data 39g obtained in step S60. Generate and save 39j.

Next, in step S110, the certification result data 39j is displayed. The display of the certification result data 39j is displayed on, for example, the insurance company terminal 102. Alternatively, the assessment result may be transmitted from the insurance company terminal 102 to the contractor terminal 101 and displayed. FIG. 11 shows an example of a certification result display screen (main screen). As shown in FIG. 11, on the certification result display screen, "case information" including contractor (patient) name, medical institution name, etc., "derived disease name list", "surgery / treatment list", and "certification result information" Information such as is displayed. 12A and 12B show a sub-screen displayed from the main screen shown in FIG. 11, FIG. 12A is a screen of a list of all derived disease names, and FIG. 12B is a screen of medical details unmatched information.

In the present embodiment, in addition to displaying the certification result data 39j, a PDF file of the certification result data 39j can be generated and downloaded via the communication network N.

As described above, the insurance money payment support system 100 in the present embodiment includes the receiving means 10, the input means 20, the recording means 30, the processing means 40, the control means 50, the display means 60, and the transmission means 70. It is composed of a computer including an output means 80, and is configured to derive a corresponding injury / illness name based on a medical statement issued by a medical institution and determine whether or not insurance money can be paid. Based on the medical statement prepared free of charge by the medical institution at the time of consultation, the name of the relevant injury or illness is derived and whether or not the insurance money can be paid is determined.

As a result, the policyholder can claim the insurance money without a medical certificate, and can save the medical certificate preparation fee. In addition, since a medical certificate is not required, it is possible to reduce the work and time required to create a medical certificate at a medical institution (doctor, etc.). In addition, the certified person in charge of the insurance company does not require human judgment, which reduces the burden of paperwork and makes it possible to obtain more accurate judgment results, realizing appropriate and early payment to policyholders. be able to.

In addition, when claiming insurance money, there is no need for time to request the creation of a medical certificate or receive the medical certificate. For doctors (medical professionals), the time to prepare a medical certificate will be reduced, which will be beneficial in terms of "work style reform". In addition, for insurance companies that pay insurance claims, the work of attaching medical certificates is reduced, which shortens the period from the policyholder's claim for insurance claims to the payment of insurance claims. By shortening the time from claim to payment, the service to policyholders will be improved.

In addition, regarding the certification work, the homogeneity of the certification content will be improved for the same etiology and pathophysiology (examination, examination, treatment) that may result from misinterpretation depending on the number of years of work experience and the amount of knowledge of the person in charge. Therefore, the work of determining whether or not to pay the insurance money and the amount of insurance will be streamlined, and the re-examination work will be reduced.

In addition, the contractor can make an online claim for insurance money on the medical statement via the communication network N.

The program for the insurance claim payment support system 100 as another embodiment of the present invention makes the computer realize the above-mentioned processing function. Further, the recording medium as another embodiment of the present invention is a recording medium that can be read by a computer in which the above program is recorded.

That is, the recording medium of the present invention is a hard disk (HDD), a flash memory, an FD (floppy (registered trademark) disk), a CDROM (compact disk), an MO (magneto-optical disk), or a DVD (digital video) on which the above program is recorded. It is a medium such as a disk).

In the above-described embodiment, the example in which the insurance money payment support system 100 and the insurance company terminal 102 are separately installed has been described, but the present invention is not limited thereto. The insurance money payment support system 100 and the insurance company terminal 102 may be installed together. For example, the insurance money payment support system 100 may be installed in the insurance company. Further, the contractor (user) may submit information such as a medical statement to the insurance company by mail or the like without providing the contractor terminal 101.

Further, in the above-described embodiment, the example in which the insurance money payment support system 100 includes the data conversion means 41 for converting the character string of the treatment action content described in the medical statement into data as text data has been described. The invention is not limited to this. For example, text data may be input from the insurance company terminal 102 and transmitted to the insurance claim payment support system 100.

The present invention is not limited to the above-described embodiment, and includes various redesigned forms within the technical scope within the range not deviating from the gist of the invention described in the claims.

The present invention can be used for the purpose of determining whether or not to pay insurance claims based on a medical statement prepared by a medical institution.

10 Receiving means 20 Input means 30 Recording means 30a Program 31 Medical statement dictionary master 32 Indication disease name master 33 Disease name extraction rule master 34 Disease name derivation rule master 35 Terms and conditions master 36 Surgery / treatment master 37 Combination master 38 Accuracy master 39a Medical statement Text data 39b Contractor (user) data 39c Case data 39d Medical practice data 39e Indication disease name data 39f Disease name derivation data 39g Injury / disease applicable data 39h Surgery / treatment data 39i Surgery / treatment applicable data 39j Certification result data 40 Processing means 41 Data conversion Means 42 Medical practice data creation means 43 Indication disease name data creation means 44 Disease name derivation means 45 First payment judgment means 46 Surgery / treatment data creation means 47 Second payment judgment means 48 Certification result data creation means 49 Dictionary update means 50 Control Means 60 Display means 70 Transmission means 80 Output means 100 Insurance claim payment support system 101 Contractor terminal 102 Insurance company terminal 103 Medical practice master 104 Pharmaceutical master N communication network

Claims (13)

It is an insurance payment support system that determines whether or not insurance payment is possible based on the medical statement.
A recording means that stores information including a pre-created medical statement dictionary master, indication disease name master, disease name extraction rule master, disease name derivation rule master, contract / special contract master, surgery / treatment master, combination master, and accuracy master.
Regarding the relationship between the medical practice and the medical practice code provided by the Ministry of Health, Labor and Welfare, refer to the medical statement dictionary master and assign the medical practice code to the text data of the medical practice content described in the medical statement. And the medical practice data creation means to create medical practice data,
From the medical practice data, a combination capable of classifying the action for the purpose of diagnosing the disease name and the action for the purpose of treatment, collating with the combination master for the action for the purpose of diagnosing the disease name, and specifying the name of the injury or illness is obtained. For actions aimed at extraction and treatment, collate with the accuracy master, sort by specific accuracy of injury / illness name, exclude data for which accuracy has not been set, and determine medical practice and accuracy of indication disease name and indication disease name. Regarding the relationship, the indication disease name data creation means for creating the indication disease name data by adding the accuracy information of the corresponding indication disease name and the indication disease name by referring to the indication disease name master and the disease name extraction rule master, and
A disease name derivation means for deriving at least a highly accurate disease name from the indication disease name data based on a disease name derivation rule created in advance from the indication disease name data.
Based on the disease name derived by the disease name derivation means, the first payment judgment means for determining whether or not the insurance is eligible for payment by referring to the insurance contract / special contract master .
Surgery / treatment data creation means that extracts information on surgery / treatment from the medical practice data, assigns a code for classifying medical practice provided by the Ministry of Health, Labor and Welfare, and creates surgery / treatment data.
The insurance money is characterized by having a second payment judgment means for judging whether or not the insurance money is payable by referring to the insurance policy / special contract master based on the operation / treatment data. Payment support system. Refer to the medical statement dictionary master for the relationship between the drug name and the drug code provided by the Ministry of Health, Labor and Welfare, and the relationship between the medical practice name including examination and surgery and the medical practice code provided by the Ministry of Health, Labor and Welfare . The claim is characterized in that it is a means for creating medical practice data by assigning the drug code and the medical practice code to the text data of the medical practice content described in the medical statement. The insurance claim payment support system described in 1. The certification result data creation means for creating the insurance claim payment availability result information determined by the first payment judgment means and the second payment judgment means as the certification result data, and the certification result data creation means.
The insurance claim payment support system according to claim 1 or 2, further comprising a means for notifying the contractor terminal of the certification result data . The insurance claim according to any one of claims 1 to 3, further comprising a data conversion means for converting a character string of medical practice contents described in the medical statement into data as text data. Payment support system. The insurance claim payment support system according to claim 4, wherein the data conversion means is a means for converting a character string of the medical practice content into text data by OCR. When assigning a drug code or a medical practice code to the text data, a dictionary update means for adding and correcting the text data that does not match the medical statement dictionary master and cannot be assigned the code to the medical statement dictionary master. The insurance claim payment support system according to any one of claims 1 to 5, further comprising. It is an insurance payment support program that determines whether or not insurance payment is possible based on the medical statement.
Computer,
A recording means that stores information including a medical statement dictionary master, an indication disease name master, a disease name extraction rule master, a disease name derivation rule master, a contract / special contract master, a surgery / treatment master, a combination master, and an accuracy master.
Regarding the relationship between the medical practice and the medical practice code provided by the Ministry of Health, Labor and Welfare, refer to the medical statement dictionary master and assign the medical practice code to the text data of the medical practice content described in the medical statement. And the medical practice data creation means to create medical practice data,
From the medical practice data, a combination capable of classifying the action for the purpose of diagnosing the disease name and the action for the purpose of treatment, collating with the combination master for the action for the purpose of diagnosing the disease name, and specifying the name of the injury or illness is obtained. For actions aimed at extraction and treatment, collate with the accuracy master, sort by specific accuracy of injury / illness name, exclude data for which accuracy has not been set, and determine medical practice and accuracy of indication disease name and indication disease name. Regarding the relationship, the indication disease name data creation means for creating the indication disease name data by adding the accuracy information of the corresponding indication disease name and the indication disease name by referring to the indication disease name master and the disease name extraction rule master, and
A disease name derivation means for deriving at least a highly accurate disease name from the indication disease name data based on a disease name derivation rule created in advance from the indication disease name data.
Based on the disease name derived by the disease name derivation means, the first payment judgment means for determining whether or not the insurance is eligible for payment by referring to the insurance contract / special contract master.
Surgery / treatment data creation means that extracts information on surgery / treatment from the medical practice data, assigns a code for classifying medical practice provided by the Ministry of Health, Labor and Welfare, and creates surgery / treatment data.
Insurance claim payment support characterized by functioning as a second payment determination means for determining whether or not an insurance claim is eligible for payment by referring to the insurance policy / special contract master based on the surgery / procedure data. program. The computer
Refer to the medical statement dictionary master for the relationship between the drug name and the drug code provided by the Ministry of Health, Labor and Welfare, and the relationship between the medical practice name including examination and surgery and the medical practice code provided by the Ministry of Health, Labor and Welfare . Then, the drug code and the medical practice code are attached to the text data of the medical practice content described in the medical care statement, and the medical practice code is added to the text data to function as a means for creating the medical practice data. The insurance claim payment support program according to claim 7. The computer is used as a certification result data creation means for creating certification result data of insurance claim payment availability result information determined by the first payment determination means and the second payment determination means .
The insurance claim payment support program according to claim 7 or 8, wherein the certification result data is made to function as a means for notifying the contractor terminal . The invention according to any one of claims 7 to 9, wherein the computer functions as a data conversion means for converting a character string of medical practice contents described in the medical statement into data as text data. Insurance payment support program. The insurance claim payment support program according to claim 10, wherein the computer functions as the data conversion means as a means for converting a character string of the medical practice content into text data by OCR. When the computer assigns a drug code or a medical practice code to the text data, the text data that does not match the medical statement dictionary master and cannot be assigned the code is added to the medical statement dictionary master and corrected. The insurance claim payment support program according to any one of claims 7 to 11, characterized in that it functions as a dictionary update means. A computer-readable recording medium comprising recording the program according to any one of claims 7 to 12.

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