JP7817541B2 - Insurance payment assessment support program, insurance payment assessment support method, and information processing device - Google Patents

Description

The present invention relates to an insurance payment assessment support program, an insurance payment assessment support method, and an information processing device.

Insurance such as medical insurance and accident insurance provides coverage to prepare for financial risks in the event of illness or injury. The insurance company confirms the name of the illness or surgery declared by the policyholder (patient) on the insurance claim form, etc., using a medical certificate issued by a doctor, and then compares the name with the terms and conditions at the time of the contract to determine whether or not to pay the insurance claim.

In order to pay insurance benefits based on the name of the injury, illness, surgery, etc., insurance companies often require the policyholder (patient) to submit a medical certificate issued by a doctor as evidence of the name of the injury, illness, surgery, etc. Currently, for illnesses covered by special clauses, such as the three major diseases, insurance companies require the policyholder (patient) to submit a medical certificate in order to conduct an assessment known as a "medical certificate assessment." On the other hand, for illnesses not covered by special clauses, insurance companies require the policyholder (patient) to submit a copy of the receipt from the medical institution and the receipt from the insurance pharmacy in order to conduct an assessment known as a "simplified assessment."

In addition, conventionally, systems have been known that allow policyholders to claim insurance benefits without a medical certificate by deriving the name of the relevant injury or illness based on a medical statement prepared by the medical institution at the time of consultation and determining whether or not to pay insurance benefits (see Patent Document 1, etc.).

Japanese Patent Application Laid-Open No. 2021-26738

However, in the system disclosed in Patent Document 1, the policyholder (patient) must submit image data of the medical statement from the policyholder's terminal or submit the medical statement by mail, which is time-consuming for the policyholder.

In one aspect, the present invention aims to provide an insurance payment assessment support program, an insurance payment assessment support method, and an information processing device that enable easy acquisition of reference data used in insurance payment assessments.

In one aspect, the insurance payment assessment support program is a program that causes a computer to execute a process of receiving a request for query data to be used in assessing insurance payment, referencing a memory unit that stores data used to create a medical fee statement that collectively lists information about medical procedures performed within a specified period for each patient, acquiring information about the medical procedure that corresponds to information that identifies the patient included in the acquisition request, identification information of the medical department that performed the medical procedure that is the subject of the insurance payment claim included in the acquisition request, and information about the date of treatment , as the query data, and sending the query data to the sender of the acquisition request , and in the memory unit, each piece of information about the medical procedure listed in the medical fee statement for each patient is linked to identification information of the medical department that performed the medical procedure and information about the date of treatment that are not listed in the medical fee statement.

You can easily obtain reference data to be used in insurance payment assessments.

1 is a diagram illustrating a schematic configuration of an insurance payment assessment system according to an embodiment. FIG. 2(a) is a diagram showing the hardware configuration of the linkage server, and FIG. 2(b) is a diagram showing the hardware configuration of the insurance company terminal and the medical institution server. FIG. 2 is a functional block diagram of a link server, an insurance company server, and a medical institution server. 10 is a flowchart showing a process of a cooperation server. FIG. 10 is a diagram showing an example of a hospitalization, surgery, and outpatient status report. FIG. 10 is a diagram showing an example of a medical receipt. FIG. 1 is a diagram illustrating an overview of an embodiment. FIG.

One embodiment of an insurance payment assessment system will be described in detail below with reference to Figures 1 to 7. The insurance payment assessment system of this embodiment is a system that supports insurance company payment assessment work. Payment assessments include "medical certificate assessments" when the policyholder's illness is one of the three major illnesses covered by a special contract, and "simplified assessments" when the illness is other than the three major illnesses. The insurance payment assessment system of this embodiment provides reference data as evidence required for payment assessments to the terminal used by the insurance company representative when they conduct a simplified assessment.

Figure 1 shows a schematic diagram of an insurance payment assessment system 100 according to one embodiment. As shown in Figure 1, the insurance payment assessment system 100 comprises a linkage server 10 as an information processing device, an insurance company terminal 30, and a medical institution server 40. The insurance company terminal 30 is connected to a network N1 such as the Internet, and the medical institution server 40 is connected to a network N2 such as a regional medical network. Note that each of the networks N1 and N2 uses SSL (Secure Sockets Layer) or VPN (Virtual Private Network), which greatly reduces the possibility of information leaks or interception.

The linking server 10 is connected to both networks N1 and N2 and handles data exchange between the insurance company terminal 30 and the medical institution server 40. More specifically, when the linking server 10 receives a request from the insurance company terminal 30 to acquire reference data to be used for simplified assessment, it requests the reference data from the medical institution server 40 and transmits the reference data received from the medical institution server 40 to the insurance company terminal 30.

Figure 2(a) shows the hardware configuration of the linkage server 10. The linkage server 10 includes a CPU (Central Processing Unit) 90, ROM (Read Only Memory) 92, RAM (Random Access Memory) 94, storage (HDD (Hard Disk Drive) or SSD (Solid State Drive)) 96, a network interface 97, and a portable storage medium drive 99. These components of the linkage server 10 are connected to a bus 98. In the linkage server 10, the CPU 90 executes programs (including an insurance payment assessment support program) stored in the ROM 92 or storage 96, or programs read from the portable storage medium 91 by the portable storage medium drive 99, thereby realizing the functions of the components shown in Figure 3. Note that the functions of the components of the linkage server 10 in Figure 3 may also be implemented by integrated circuits such as ASICs (Application Specific Integrated Circuits) and FPGAs (Field Programmable Gate Arrays). Details of the components in Figure 3 will be described later.

Returning to Figure 1, the insurance company terminal 30 is a terminal used by insurance company personnel, and has the function of sending requests to the linkage server 10 to obtain reference data to be used for simplified appraisals, and receiving and displaying reference data from the linkage server 10.

The insurance company terminal 30 has a hardware configuration as shown in FIG. 2(b). Specifically, the insurance company terminal 30 includes a CPU 190, ROM 192, RAM 194, storage 196, network interface 197, display unit 193, input unit 195, and a portable storage medium drive 199 capable of reading data stored on the portable storage medium 191. The display unit 193 includes an LCD display or the like, and the input unit 195 includes a keyboard, mouse, touch panel, or the like. These components of the insurance company terminal 30 are connected to a bus 198. In the insurance company terminal 30, the CPU 190 executes programs to realize the functions of the components shown in FIG. 3.

The medical institution server 40 is connected to user terminals used by medical professionals, such as doctors, via a LAN (Local Area Network). The medical institution server 10 is an information processing device that manages data on medical fee statements (referred to as "receipts") created on user terminals in a receipt database 46 (see Figure 3). Receipt data, such as those shown in Figure 6, is issued monthly. Receipt data includes the patient's name, date of birth, name of illness or injury, start date of treatment, outcome (recovery, death, discontinuation), information about the treatment, and information about hospitalization. Note that receipt database 46 may also store information not included on the receipt. For example, receipt database 46 stores information about the medical department that performed each treatment listed on the receipt, along with date information. Receipt data may be either fee-for-service or Diagnosis Procedure Combination (DPC) receipts based on the DPC system. The DPC system is a comprehensive medical fee payment system that uses a comprehensive payment system to calculate inpatient medical fees based on a flat rate per day determined by the disease and treatment content (diagnosis group classification). The DPC system was introduced by the Ministry of Health, Labour and Welfare with the aim of standardizing the quality of medical care.

As an example, the medical institution server 40 has the same hardware configuration as the insurance company terminal 30 (Figure 2(b)). In the medical institution server 40, the CPU 190 executes a program to realize the functions of each unit shown in Figure 3. Note that the functions of each unit of the medical institution server 40 in Figure 3 may also be realized by an integrated circuit such as an ASIC or FPGA.

Figure 3 shows a functional block diagram of the insurance company terminal 30, link server 10, and medical institution server 40.

(Functions of the insurance company terminal 30)
As shown in FIG. 3 , the insurance company terminal 30 includes an acquisition request transmitter 32 and a reference data receiver 34. When an insurance company representative performs a "simple assessment," the representative inputs a request for reference data. When making this request, the representative inputs predetermined information (information identifying the policyholder (patient) and information identifying the medical procedure in question). The information identifying the patient includes the patient's identification information (e.g., patient ID). The information identifying the medical procedure in question includes the medical institution's identification information (e.g., hospital code), the medical department's identification information (e.g., medical department code), and information on the date of medical treatment. The insurance company representative inputs the predetermined information into the insurance company terminal 30 by referring to the "Hospitalization, Surgery, and Outpatient Status Report" (see FIG. 5 ), which is submitted by the policyholder (patient) and written by the policyholder himself/herself.

When a request to acquire reference data (including the above-mentioned specified information) is input by an insurance company employee, the acquisition request sending unit 32 sends the request to acquire reference data to the linked server 10.

When query data is sent from the linked server 10, the query data receiving unit 34 receives the query data and displays it on the display unit 193.

(Functions of Linkage Server 10)
As shown in Figure 3, the linked server 10 has an acquisition request receiving unit 12 as a receiving unit, a medical institution identification unit 14, a query data request unit 16, a query data acquisition unit 18, an insurance company identification unit 20, and a query data transmission unit 22 as a transmitting unit.

The acquisition request receiving unit 12 receives an acquisition request transmitted from the acquisition request transmitting unit 32 of the insurance company terminal 30. The medical institution identifying unit 14 checks the medical institution identification information (such as a hospital code) included in the acquisition request and identifies which medical institution server 40 the query data should be requested from. The query data requesting unit 16 executes a process to request query data from the medical institution server 40 identified by the medical institution identifying unit 14. At this time, the query data requesting unit 16 transmits to the medical institution server 40 the patient identification information (such as a patient ID), medical department identification information (medical department code), and information on the date of medical treatment included in the acquisition request.

The query data acquisition unit 18 acquires query data transmitted from the medical institution server 40. The insurance company identification unit 20 identifies to which insurance company terminal 30 the acquired query data should be sent. Specifically, the insurance company identification unit 20 identifies which patient the acquired query data belongs to, and identifies the insurance company terminal 30 that most recently transmitted a request to acquire query data for that patient. The query data transmission unit 22 transmits the query data to the insurance company terminal 30 identified by the insurance company identification unit 20.

(Functions of medical institution server 40)
3, the medical institution server 40 includes a request receiving unit 42 and a data extracting unit 44. As described above, the medical institution server 40 manages medical receipt data in the medical receipt DB 46.

When the request receiving unit 42 receives a request to acquire query data from the query data request unit 16 of the linked server 10, it accepts the acquisition request and notifies the data extraction unit 44 of the information included in the acquisition request (patient identification information, medical department identification information, and information on the date of medical treatment).

When the data extraction unit 44 receives a notification from the request reception unit 42, it references the medical receipt DB 46 and identifies the medical receipt data corresponding to the patient's identification information. The data extraction unit 44 also extracts data corresponding to the medical department identification information and the date of medical treatment from the acquired medical receipt data, and uses the extracted data as query data. The data extraction unit 44 transmits the query data to the linkage server 10.

(Regarding the processing of the linking server 10)
Next, the processing of the link server 10 will be described in detail with reference to the flowchart of FIG.

When the processing in Figure 4 begins, first, in step S10, the acquisition request receiving unit 12 waits until a request to acquire reference data is received. When the acquisition request transmitting unit 32 of the insurance company terminal 30 transmits the acquisition request along with the information entered by the insurance company representative (patient identification information, medical institution identification information, medical department information, and treatment date information), the acquisition request receiving unit 12 proceeds to step S12.

When proceeding to step S12, the acquisition request receiving unit 12 receives the acquisition request and notifies the medical institution identification unit 14.

Next, in step S14, the medical institution identification unit 14 identifies the medical institution requesting the query data from the medical institution identification information included in the acquisition request, and notifies the query data request unit 16.

Next, in step S16, the query data request unit 16 sends the information included in the acquisition request (patient identification information, medical department information, and consultation date information) to the medical institution server 40 of the medical institution identified by the medical institution identification unit 14. As a result, the query data request unit 16 requests query data for simplified assessment from the medical institution server 40.

In the medical institution server 40, the request reception unit 42 notifies the data extraction unit 44 of the patient's identification information, medical department information, and treatment date information. The data extraction unit 44 then references the medical receipt DB 46 to identify the medical receipt data corresponding to the patient's identification information. Because a medical receipt is a document that lists all medical procedures for one month, if a patient visits the hospital for multiple illnesses, it is difficult to determine the medical procedures and treatment points that are the subject of an insurance claim just by looking at the receipt. In contrast, in this embodiment, as described above, the medical receipt DB 46 stores data for each medical procedure listed on the receipt in association with medical department identification information and treatment date information. Therefore, the data extraction unit 44 extracts data corresponding to the medical department identification information and treatment date information from the medical receipt data corresponding to the patient's identification information as reference data to be used for simplified assessment. The data extraction unit 44 transmits the extracted reference data to the linkage server 10.

After step S16, in step S18, the query data acquisition unit 18 waits until query data is transmitted from the medical institution server 40. Therefore, when query data is transmitted from the data extraction unit 44, the query data acquisition unit 18 proceeds to step S20 and acquires the query data.

Next, in step S22, the insurance company identification unit 20 identifies which insurance company the query data should be sent to. In this case, the insurance company identification unit 20 identifies the insurance company terminal 30 that sent the request to obtain query data for the patient based on the patient's identification information contained in the query data. The insurance company identification unit 20 notifies the query data transmission unit 22 of the information about the identified insurance company terminal 30.

Next, in step S24, the inquiry data sending unit 22 sends the inquiry data to the identified insurance company terminal 30. In the insurance company terminal 30, the inquiry data receiving unit 34 receives the inquiry data and displays the inquiry data on the display unit 193 of the insurance company terminal 30. This allows the insurance company representative to use the inquiry data as evidence to assess (simple assessment) the payment of insurance money to the policyholder (patient).

In this embodiment, the query data request unit 16 and the query data acquisition unit 18 function as an acquisition unit that acquires, as query data, the prescription data corresponding to the acquisition request from the medical institution server 40.

Figure 7 shows a schematic overview of this embodiment. As shown in Figure 7, in this embodiment, (1) the policyholder (patient) submits a hospitalization, surgery, and outpatient status report (Figure 5) to receive insurance payment. Next, (2) the insurance company representative, while reviewing the hospitalization, surgery, and outpatient status report, inputs a request to acquire query data. (3) The insurance company terminal 30 transmits the input acquisition request to the linkage server 10. (4) The linkage server 10 receives the acquisition request (S12 in Figure 4) and transmits a request to acquire query data to the medical institution server 40 that manages the medical receipt data. (5) The medical institution server 40 extracts data corresponding to the acquisition request as query data, and (6) transmits the query data to the linkage server 10, which then acquires the query data (S20 in Figure 4). Then, (7) the linkage server 10 transmits the acquired query data to the insurance company terminal 30 (S24 in Figure 4). As a result, (8) the display unit 193 of the insurance company terminal 30 displays the policyholder's (patient's) receipt data as reference data. Therefore, the insurance company representative can use the reference data as evidence to perform a simplified assessment. In this case, the policyholder (patient) does not need to submit the receipt (document) to the insurance company by mail or send the receipt's electronic data to the insurance company terminal 30, thereby reducing the policyholder's (patient's) workload. While receipts issued by medical institutions and insurance pharmacies have traditionally been used for simplified assessments, receipts contain all the information listed on receipts, so there is no problem using receipt data as evidence for simplified assessments. Furthermore, when requesting reference data ((2) in Figure 7), the insurance company representative inputs the medical institution's identification information, as well as the medical department's identification information and the date of treatment. Therefore, the medical institution server 40 can extract data on the medical treatment and disease name covered by the insurance as reference data, even if the receipt contains information on medical treatments for multiple injuries or illnesses.

In the above embodiment, the linkage server 10 acquires query data from the medical institution server 40 and transmits the acquired query data directly to the insurance company terminal 30. However, this is not limited to this. For example, as shown in FIG. 8, the linkage server 10 may have the functionality of a report creation unit 24. The report creation unit 24 creates a hospitalization, surgery, and outpatient status report (see FIG. 5) based on the query data acquired by the query data acquisition unit 18. In this case, the query data transmission unit 22 transmits the query data as evidence to the insurance company terminal 30 along with the hospitalization, surgery, and outpatient status report created by the report creation unit 24. This eliminates the need for the policyholder (patient) to fill out the hospitalization, surgery, and outpatient status report; they only need to provide the insurance company representative with the information necessary to acquire the query data (such as the patient's identification information). In the example of FIG. 8, the report creation unit 24 and the query data transmission unit 22 function as a creation unit that uses the query data to create the report necessary for payment assessment and transmits the created report to the insurance company terminal 30.

In the above embodiment, the linked server 10 provides medical receipt data as evidence when an insurance company performs a "simple assessment," but this is not limited to this. For example, if it becomes possible to use medical receipt data as evidence in the future for a "medical certificate assessment," query data can be provided to the insurance company terminal 30 for the "medical certificate assessment" in the same way as in the above embodiment.

In the above embodiment, a case where receipt data is sent to the insurance company terminal 30 as inquiry data is described, but this is not limited to this. If there is data that can be used as inquiry data (data created in accordance with medical treatment), at least a portion of that data may be provided to the insurance company terminal 30 as inquiry data. Possible data that can be used as inquiry data includes, for example, survey files related to the impact assessment of the introduction of the DPC system.

In the above embodiment, a case has been described in which the network to which the insurance company terminal 30 is connected is different from the network to which the medical institution server 40 is connected. However, this is not limited to this, and for example, the insurance company terminal 30 and the medical institution server 40 may be connected to the same network.

In the above embodiment, the medical institution server 40 manages the medical receipt data, but this is not limited to this. For example, the linking server 10 may acquire the medical receipt data from the medical institution server 40 or the like and manage it in the storage unit of the linking server 10. In this case, when the linking server 10 acquires a request to acquire query data from the insurance company terminal 30, it may extract the medical receipt data corresponding to the acquisition request from the storage unit and send it to the insurance company terminal 30.

The above processing functions can be realized by a computer. In this case, a program is provided that describes the processing details of the functions that the processing device should have. By executing the program on a computer, the above processing functions are realized on the computer. The program that describes the processing details can be recorded on a computer-readable storage medium (excluding carrier waves, however).

When distributing a program, it is sold, for example, in the form of a portable storage medium on which the program is recorded, such as a DVD (Digital Versatile Disc) or a CD-ROM (Compact Disc Read Only Memory). The program can also be stored in the storage device of a server computer, and then transferred from the server computer to other computers via a network.

A computer that executes a program stores, for example, a program recorded on a portable storage medium or a program transferred from a server computer in its own storage device. The computer then reads the program from its own storage device and executes processing in accordance with the program. Note that the computer can also read the program directly from a portable storage medium and execute processing in accordance with that program. The computer can also execute processing in accordance with the received program each time a program is transferred from the server computer.

The above-described embodiment is a preferred example of the present invention. However, it is not limited to this, and various modifications are possible within the scope of the gist of the present invention.

In addition, the following supplementary notes are disclosed in relation to the above-described embodiments.
(Note 1) Receive a request to acquire reference data used in insurance payment assessment,
acquires, as the inquiry data, data corresponding to information for identifying the patient included in the acquisition request and information for identifying the medical treatment for which the insurance payment claim is made included in the acquisition request from a storage unit that stores document data created in response to the medical treatment;
transmitting the inquiry data to the sender of the acquisition request;
An insurance payment assessment support program that causes a computer to execute processing.
(Appendix 2) The insurance payment assessment support program described in Appendix 1, characterized in that the computer is further caused to execute a process of creating a report necessary for payment assessment using the acquired inquiry data and sending the created report to the sender.
(Note 3) The assessment of the payment of the insurance claim is a simplified assessment conducted for illnesses other than those covered by the special contract.
The insurance payment assessment support program described in Appendix 1 or 2, characterized in that in the acquisition process, data corresponding to information identifying the patient included in the acquisition request and information identifying the medical treatment for which the insurance payment claim is made included in the acquisition request is acquired as the inquiry data from the medical fee statement data stored in the memory unit.
(Appendix 4) An insurance payment assessment support program as described in Appendix 3, characterized in that the information identifying the medical treatment for which the insurance payment claim is made includes identification information for the medical institution, identification information for the medical department, and information on the date of the treatment.
(Appendix 5) Receive a request to acquire reference data used in insurance payment assessment,
acquires, as the inquiry data, data corresponding to information for identifying the patient included in the acquisition request and information for identifying the medical treatment for which the insurance payment claim is made included in the acquisition request from a storage unit that stores document data created in response to the medical treatment;
transmitting the inquiry data to the sender of the acquisition request;
An insurance payment assessment support method characterized in that processing is executed by a computer.
(Supplementary Note 6) A receiving unit that receives a request to acquire reference data used in insurance payment assessment;
an acquisition unit that acquires, as the inquiry data, data corresponding to information identifying the patient included in the acquisition request and information identifying the medical treatment for which the insurance payment claim is made included in the acquisition request from a storage unit that stores document data created in response to the medical treatment;
a transmission unit that transmits the inquiry data to a sender of the acquisition request;
An information processing device comprising:
(Supplementary Note 7) The information processing device according to Supplementary Note 6, further comprising a creation unit that creates a report necessary for payment assessment using the inquiry data acquired by the acquisition unit, and transmits the created report to the sender.
(Note 8) The assessment of the payment of the insurance claim is a simplified assessment conducted for illnesses other than those covered by the special contract.
The information processing device described in Appendix 6 or 7, characterized in that the acquisition unit acquires data from the medical fee statement data stored in the memory unit that corresponds to information identifying the patient included in the acquisition request and information identifying the medical procedure that is the subject of the insurance payment claim included in the acquisition request as the query data.
(Appendix 9) An information processing device as described in Appendix 8, characterized in that the information specifying the medical treatment for which the insurance payment claim is made includes identification information of the medical institution, identification information of the medical department, and information on the date of the treatment.

10. Collaboration server (information processing device)
12 Acquisition request receiving unit (receiving unit)
16. Inquiry data request unit (part of the acquisition unit)
18. Inquiry data acquisition unit (part of the acquisition unit)
22 Inquiry data transmission unit (transmission unit, part of creation unit)
24 Report Preparation Department (Part of the Preparation Department)
40 Medical institution server (storage unit)
46 Receipt DB

Claims (5)

Receive a request to acquire reference data to be used in insurance payment assessment;
Refer to a storage unit that stores data used to create a medical fee statement that collectively lists information about medical procedures performed for each patient within a specified period, and acquire, as the inquiry data, information about the medical procedure that corresponds to the information that identifies the patient included in the acquisition request, the identification information of the medical department that performed the medical procedure that is the subject of the insurance payment claim included in the acquisition request, and the information about the date of the medical procedure ;
transmitting the inquiry data to the sender of the acquisition request;
Have the computer execute the process ,
An insurance payment assessment support program characterized in that, in the memory unit, each piece of information about the medical procedure listed on each patient's medical fee statement is linked to the identification information of the medical department that performed the medical procedure and information about the date of the treatment, which are not listed on the medical fee statement. The insurance payment assessment support program of claim 1 further causes the computer to execute a process of using the acquired inquiry data to create a report necessary for the payment assessment and sending the created report to the sender. The insurance payment assessment support program according to claim 1 or 2, characterized in that the insurance payment assessment is a simplified assessment conducted for illnesses other than those covered by special contracts. Receive a request to acquire reference data to be used in insurance payment assessment;
Refer to a storage unit that stores data used to create a medical fee statement that collectively lists information about medical procedures performed for each patient within a specified period, and acquire, as the inquiry data, information about the medical procedure that corresponds to the information that identifies the patient included in the acquisition request, the identification information of the medical department that performed the medical procedure that is the subject of the insurance payment claim included in the acquisition request, and the information about the date of the medical procedure ;
transmitting the inquiry data to the sender of the acquisition request;
The computer executes the processing ,
An insurance payment assessment support method characterized in that, in the memory unit, each piece of information about the medical procedure listed on the medical fee statement for each patient is linked to the identification information of the medical department that performed the medical procedure and information about the date of the procedure, which are not listed on the medical fee statement. a receiving unit that receives a request to acquire reference data used in insurance payment assessment;
an acquisition unit that refers to a storage unit that stores data used to create a medical fee statement that collectively lists information about medical procedures performed within a specified period for each patient, and acquires, as the inquiry data, information about the medical procedure that corresponds to information that identifies the patient included in the acquisition request, identification information of the medical department that performed the medical procedure that is the subject of the insurance payment claim included in the acquisition request, and information about the date of the medical procedure;
a transmission unit that transmits the inquiry data to a sender of the acquisition request;
Equipped with
In the memory unit, an information processing device in which each piece of information about the medical procedure listed on each patient's medical fee statement is linked to the identification information of the medical department that performed the medical procedure and information about the date of the treatment, which are not listed on the medical fee statement .