Research On The Fraud Monitoring Of Social Medical Insurance

Social medical insurance fraud(hereinafter referred to as "medical insurance fraud")is a serious problem that is widespread in the world,and many countries suffer from it.According to the data released by the National Medical Security Administration,since 2019,a total of 264,000 designated medical service institutions have been investigated and dealt with suspected of medical insurance fraud and fraud,and 33,100 insured persons suspected of violations of laws and regulations have been dealt with.A total of 11.556 billion yuan of fraudulent insurance funds were recovered in accordance with the law throughout the year.Social medical insurance fraud monitoring refers to the whole process of monitoring,identifying and measuring various social medical insurance fraud frauds through certain methods and methods.Social medical insurance fraud monitoring is an important basic work to combat fraudulent insurance fraud.The efficient monitoring of medical insurance fraud has important significance and role in combating medical insurance fraud fraudulent activities.Based on the literature research,this paper designs interview outlines and data survey forms,and selects city A in northern Jiangsu,city B in central Jiangsu,and city C in southern Jiangsu as sample areas.The site survey collected from September to October 2020.Medical insurance fraud related data and medical insurance monitoring related data.Using the principles of t-SNE and KNN,dimensionality reduction processing and abnormal data mining processing are performed on the collected data.As a result,it was found that there were 41 abnormal data,and then the type of fraud was judged according to the rule definition through manual verification,and finally a total of 8 cases of hospital fraud and insurance fraud were identified.At the same time,the following problems were found in the monitoring of medical insurance fraud:(1)the intelligent monitoring system failed to communicate and share;(2)the intelligent monitoring system data was not perfect;(3)the indicators of the intelligent monitoring system surfaced;(4)fraud monitors were overburdened.Based on the above issues,the suggestions for improving the monitoring of social medical insurance frauds are as follows:(1)establish a unified medical insurance monitoring platform;(2)improve the quality of monitoring data;(3)train professional supervision teams;(4)actively introduce third parties and Social supervision;(5)actively promote the integration of the medical insurance credit system and monitoring system.