Recently,Wisdom Eye won the bid for the country's first provincial-level medical insurance anti-fraud big data project - Xinjiang Corps Medical Security Bureau's medical insurance anti-fraud big data supervision and application project, further enrich the means of medical insurance supervision, demonstrate the power of the crackdown, purify the industry ecology, and create a new chapter in medical insurance governance.
At the same time, the smart eye medical insurance anti-fraud big data model has been piloted in Hunan, Henan and other provinces, effectively improving the efficiency of supervision, effectively preventing the occurrence of "fake patients, fake diseases, fake bills" and gang fraud and insurance fraud, forming a three-dimensional supervision system combined with unannounced inspections and existing regulatory means, providing replicable, reference, and generalizable experience, standards and models for the whole country.
Over the years, with its profound industry cognition, rich practical experience in medical reform, perfect technical service support, strong professional service team and other advantages, Wisdom Eye has helped medical insurance run out of the sample road, and has completed the construction of 21 provincial medical insurance intelligent scene monitoring systems (medical insurance supervision) across the country, and has achieved the effect of combating fraud and fraud, standardizing the use of medical insurance, and ensuring safety. At the same time, after the completion of the acquisition of Changtian Technology, a subsidiary of Ping An Medical, Wisdom Eye undertook the construction and operation and maintenance of the data middle platform and macro decision-making systems in nearly ten provinces including Hunan, Shaanxi, Liaoning, Hainan, Tianjin, and Heilongjiang, further strengthening our service capabilities in the core business of medical insurance.
With the deepening of the medical insurance reform, the characteristics of medical insurance users are more, the chain is long, the risk points are many, and the supervision is more difficult, and the outstanding problems such as "difficult to find, difficult to obtain evidence, and difficult to collect" still exist in the supervision, and problems such as "lack of multi-dimensional analysis, insufficient clues, insufficient cluster analysis, lack of relationship results, and incomplete credit system" have become the "roadblocks" of weaving a dense medical insurance supervision network, and it is difficult for conventional technical means to find all these "wearing invisibility clothing" insurance fraud.
In the context of digital transformation, the use of big data and artificial intelligence technology to build an all-round, multi-level and three-dimensional regulatory system and establish a safety barrier for medical insurance is not only the future direction, but also an inevitable choice.
By giving full play to the advantages of artificial intelligence, data intelligence, knowledge graph and privacy computing technology, the smart eye medical insurance anti-fraud big data model aims to achieve point-based group results through clue monitoring, cluster analysis, trajectory link, behavior trend and relationship graph in different scenarios, enrich the medical insurance supervision tools, focus on risk behavior mining with rules, and use data monitoring area, model center, The main functions such as the application center and the leadership cockpit realize the business closed-loop of model construction, risk early warning, correlation analysis, evaluation report, audit and disposal, and realize early perception, quick identification, quasi-reminder and joint prevention and control of medical insurance fraud risks.
Tracing the source
Based on privacy computing, an anti-fraud data monitoring area is formed
Based on the long-term consideration of data sharing, data security and medical insurance management-service-reform, the anti-fraud data monitoring area relies on the medical insurance data middle platform and privacy computing technology to realize vertical and horizontal multi-source heterogeneous data access and offline data access. The desensitized data of horizontal departments such as the Food and Drug Administration or the data of joint model parameters are accessed, and the system forms a special area for medical insurance anti-fraud data monitoring with hierarchical and classified management through a series of data governance methods and data exploration technologies.
Peel back the threads
Through big data related technologies, we will build an anti-fraud central brain
Based on big data technologies such as artificial intelligence, data intelligence, and knowledge graph, Wisdom Eye gives priority to the formation of risk graphs of individuals, families, insured units, medical institutions, practitioners, and production and circulation enterprises, and at the same time builds ideas based on the iterative analysis of discovery-association-diffusion models, focuses on risk behavior mining with rules, and uses knowledge graphs, similarity analysis, correlation analysis and multi-layer pipline joint modeling to form a point-to-surface, bar-to-block, vertical-to-horizontal big data anti-fraud central brain. In terms of the discovery of unknown risks and scale risks, the anti-fraud central brain can reflect the core advantages of clue discovery, clue prediction, trend prediction, relationship and group result mining.
There's nothing to hide
Relying on the central brain of anti-fraud, a data model for key scenarios is formed
Combined with the requirements of the National Health Insurance Administration, Wisdom Eye has established an "anti-fraud data monitoring area" based on artificial intelligence and big data technology, built accurate user portraits, and focused on strengthening the supervision of key areas such as hemodialysis, orthopedics, mental diseases, and examinations. Establish clue monitoring methods such as monitoring of insured personnel, monitoring of medical institutions, and monitoring of medical behaviors in key areas, institutions, drug consumption, and personnel, and establish a number of big data models such as gathering medical treatment and drug purchases, fictitious medical service projects, and medical treatment and drug purchase by deceased persons, so as to accurately capture, amplify, and crack down on illegal objects, illegal and illegal behaviors.
Knowing by the subtlety
Establish an early warning and sharing center for abnormal clues, and open up multi-department joint law enforcement
The abnormal clue early warning center is the real-time violation capture and push of the data model by the anti-fraud central brain, and it is also the main path for the tracking of abnormal clues to be deeply amplified, so as to facilitate the audit and law enforcement personnel to further analyze and judge the abnormal information, conduct online and offline audits and administrative punishments, interview, order corrections, circulate criticism, suspend medical insurance, terminate medical insurance agreements, transfer to medical insurance administrative departments, transfer to judicial organs, transfer to discipline inspection and supervision organs, and implement business closed-loop such as refusal to pay, recovery of funds, collection of liquidated damages, fines, etc.
Through the deep integration of medical insurance business and intelligent technology, the smart eye medical insurance anti-fraud big data model weaves an efficient, rigorous and sensitive data supervision network, and builds a full-process, full-cycle and refined medical insurance supervision system, so as to achieve fraud risk perception and protection in the pre-event stage, attack detection and protection in the mid-event stage, and threat countermeasures and response in the post-event stage.
Medical security is of great practical significance to reduce the economic burden of medical treatment for the people, promote social fairness, and maintain social stability. The National Health Insurance Administration has repeatedly emphasized that the medical security industry adheres to the people's health as the center and puts safety in the first place.
In order to further promote the high-quality development of the medical insurance industry, Wisdom Eye will take the gathering, communication and use of artificial intelligence and big data as the main line, solidly cultivate the medical insurance supervision and service capabilities, continue to improve the value of data empowerment, explore the new model of the construction of the "three-medical linkage" system, create a new platform for health security services, and promote the construction of higher quality, more efficient, fairer, safer and more sustainable health security services, so as to escort the safety of medical insurance