Due to issues such as cognitive differences and blurred boundaries, "three treatment fees" (expenses incurred from rehabilitation, physiotherapy, and traditional Chinese medicine treatments) have been maladies affecting the rational use of medical insurance funds and regulatory enforcement. The "three treatment fees" supervision model is a regulatory tool developed to address this issue, based on unsupervised self-learning for precise prediction and discovery of the unknown. By employing methods such as data preprocessing, multidimensional clustering, and suspicious physician cluster locking, the model is constructed to achieve periodic warning, real-time monitoring, and normalized handling. This model has been applied in the medical insurance supervision of a city, which can effectively identify potential suspicious physicians based on model alerts. Through inter-departmental cooperation, the model can effectively guide medical institutions and physicians to standardize their diagnosis and treatment behaviors using methods such as supervision and inspection, administrative discussions, and "driver's license" style scoring.
Key words
three treatment fees /
intelligent warning /
warning model
{{custom_sec.title}}
{{custom_sec.title}}
{{custom_sec.content}}
References
[1] 缪燕. 人口老龄化趋势下中医药特色“医康养健”四位一体养老模式探讨[J].中医药管理杂志,2022,30(14):192-194.
[2] 王君华. 从违规案例分析医保定点医疗机构稽核管理的重点[J].现代经济信息,2018(19):25-26.
[3] 国家医保局,国家卫健委,国家药监局.关于建立定点医药机构相关人员医保支付资格[EB/OL].(2024-08-23)[2024-10-15].https://www.gov.cn/zhengce/zhengceku/202409/content_6977005.htm.
[4] 殷立昇,马明丽,陈逸萌,等.医保基金智能监管研究综述[J].管理科学与工程,2023,12(3):288-294.
[5] 盛诗梦,丁皓,徐欣茹,等.注意力机制在医学上的应用综述[J].软件工程与应用,2022,11(6):1223-1232.
[6] AHMEDT-ARISTIZABAL D, ARMIN M A, DENMAN S,et al.Graph-based deep learning for medical diagnosis and analysis: past, present and future[J]. Sensors, 2021, 21(14):4758.
[7] 秦金龙,彭盼,陈放,等.基于结构深度嵌入的医疗导诊对话管理系统[J].中国信息化,2022(11):80-82.
[8] 刘昶荣.AI时代来临——医保基金穿透式监管成为可能[N].中国青年报,2024-11-09(003).
[9] 黄蛟灵,耿韬,郭静.医药机构违法违规使用医保基金原因分析及对策建议[M].中国医疗保险基金监督管理发展报告(2023-2024).2024: 122-137.