Research On The Problem And Countermeasures Of Medical Insurance Fraud Based On Large Data

Since the 17 th CPC National Congress,the medical insurance system in our country continuously is improved,and people from more and more areas enjoy the insurance.As the development of information technology,medical insurance settlement based on Internet becomes better and better,and the settlement between different areas grow continuously.This makes the medical service better and better.However,with wider and wider service range and the improvement of medical service,medical insurance fund is always received illegally for interests.This phenomenon becomes more and more serious,and interferes with normal implementation of the medical insurance system.Under the environment of“Mass Entrepreneurship and Innovation”,medical institutions become more and more,areas where they are distributed greatly,the settlement between different areas become more and more.All these make it difficult to supervise medical benefits fund and to identify fraud behaviors.Recently,in the medical industries,there are some researches about medical insurance anti-fraud through creating prescription strategies,medicines knowledge bases,etc.However,these approaches always adopt fixed strategy model,and the effects to identify anti-fraud behaviors are not ideal.For many years,a huge amount of data on medical records and drug behavior are accumulated with the continuous operation of China's medical insurance system.However,these data can't enough to be utilized.At present,big data analysis technology in various fields is applied in many industries,and has made remarkable achievements.Specially,with the rise of AI,big data has been a research focus.In the report of the 19 th CPC National Congress,deeper integration among Internet,big data,AI and entity economy would be promoted actively.These technologies can be used to solve various difficulties in medical insurance anti-fraud research.Examples are distributed areas,many people enjoying this insurance,professional diagnosis and treatment,concealed irregularities,lagging anti-fraud technologies,deficiency of auditors,and Weak disciplinary strength.The anti-fraud technologies for medical insurance based on big data will become a most accurate and effective measure for medical insurance anti-fraud work.This paper firstly analyses the essence behind the medical insurance fraud and current status,and concludes advantages and shortages of different approaches through investigation,analysis and comparison.Then,based on medical and health care data in last many years,it models and analyses them,deeply researches valid anti-fraud measures formedical insurance,and presents medical insurance anti-fraud model.Meanwhile,for Jinbao project and information platform of social insurance in various parts of China,based on medical insurance big data,a comprehensive technology system for medical insurance anti-fraud work is presented.Finally,this paper discusses the problems and countermeasures about medical insurance fraud behaviors from technology and policy views.