JP2005292936A - Payment system and method for medical insurance self-payment portion, and computer program - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide a payment system for a medical insurance self-payment portion allowing deferred payment without requiring input of a secret code number or a signature. <P>SOLUTION: A qualification authentication means confirms that an insurant is a rightful target person of forward charge service of the medical insurance self-payment portion and starts up a forward charge claim means, and the forward charge claim means claims payment of medical insurance self-payment forward charge portion to the insurant. Thereby, payment information about the medical insurance self-payment portion is provided to an insurer, and the deferred payment of the medical insurance self-payment portion is realized. <P>COPYRIGHT: (C)2006,JPO&NCIPI

Description

  The present invention relates to a medical insurance self-payment payment system and method, and a computer program, which are preferably used when paying the self-payment of medical insurance by postpay.

  In the conventional medical insurance system, each citizen takes out medical insurance such as health insurance, mutual aid association, national health insurance, etc. and pays monthly insurance premiums. A certain percentage (70%, etc.) is paid from medical insurance (hereinafter, the medical expenses paid from the medical insurance are referred to as medical insurance insurance benefits). The remaining portion (30%, etc.) of medical expenses is paid directly by each individual (hereinafter, the medical expenses corresponding to the proportion are referred to as the self-payment of medical insurance).

  The medical expenses paid from the medical insurance are each insurance insurer (health insurance association) using the receipts (medical treatment (dispensing) remuneration statement) created for each item at each medical institution such as a hospital, clinic, pharmacy, etc. , Country, local government, etc.). In practice, the receipt is often sent from each medical institution to an examination / payment institution that is a public institution. Then, after the contents of the receipt are examined by a staff member with specialized knowledge, a claim is made to each insurer in a lump. Payment is made from the insurer to each medical institution through an examination and payment institution. In this case, the period from billing to payment is usually about two months.

On the other hand, the medical expenses for the self-payment are usually settled for each medical treatment per day. The insured person goes to the accounting department of the medical institution when the medical treatment is over, and pays with cash.
As described above, payment for medical insurance insurance benefits claimed by a receipt is generally made through an examination payment organization. On the other hand, in recent years, IT (Information Technology) is used in line with deregulation, and a system that exchanges billing / payment information by receipt between a medical institution and an insurer directly without going through an examination / payment institution. Has been built. For example, in an organization that mediates transmission / reception of a large amount of receipt information between a medical institution and an insurer, there is one that employs a mechanism for returning a receipt reserved by an insurer to the medical institution (for example, Patent Document 1). ). Alternatively, there is a medical institution and an insurer provided with a means for encrypting each information in order to prevent information leakage in an intermediary organization (for example, Patent Document 2).
In addition, there are products that use a business model based on factoring to shorten the time required for cashing credits to the examination and payment institution. A point to keep in mind when factoring is that not all of the receipts issued by medical institutions are assessed at their exact cost. In other words, if there is an inappropriate point in the contents of the receipt, the amount charged may be reduced or reserved. Therefore, in the products as described above, the medical fee claim right (medical fee claim) generated at each medical institution is not treated as a claim with 100% credit, but as a certain defect. Therefore, the receivable assignee usually discounts about 80% and cashes the medical treatment receivable. Then, one or two months later, when the payment amount is fixed by the examination and payment institution, the remaining portion of the claim is paid. Therefore, the ratio of cashing at the beginning is as low as about 80%, for example.

  The above-described techniques are mainly matters relating to medical insurance insurance benefits that are claimed using a receipt. On the other hand, as for the medical insurance self-payment, it is common that payment is made on a daily basis in cash as described above. Some medical institutions have made it possible to use credit cards and debit cards (for example, Patent Document 3). However, there has been no particular technical change in the check system for claims. For example, in the same way as in the case of receipt screening, if the payment from the medical institution is reduced for the medical insurance insurance benefits, the ratio is reflected in the medical insurance self-payments. No mechanism has been established.

In addition, when an insurer examines a receipt for medical insurance benefits, it will be possible to conduct a more detailed examination if the insured can know the amount already paid by each insured. There is. Therefore, there was a request to obtain information about self-payment.
JP 2001-344337 A (page 3-4, FIG. 1) JP 2002-149813 A (page 4-5, FIG. 1) JP 2002-230156 A (pages 10-11, FIG. 11)

  As mentioned above, postpayment at the counter has not progressed much. This postpayment does not just eliminate the need for medical institutions and insured to prepare cash. For example, the following convenience improvement effects can be expected. That is, the waiting time at a medical institution is not only a waiting time before medical treatment but also a waiting time for accounting after medical treatment is a major factor. This is because, after receiving various examinations and medical treatments at various departments, it may take a relatively long time for the information to be collected for accounting, and the accounting process is complicated. Has been affected.

On the other hand, unlike ordinary sales contracts, medical institutions rarely change the content of medical practice at the time of accounting, and rarely confirm the content in advance at the time of accounting. In other words, at the time of accounting, the medical practice has already been carried out, and the contents of the medicine are all confirmed (because the service of “medical treatment” is a comprehensive commission of “cure the disease”). In addition, the amount of remuneration is generally left to medical institutions on the spot. Therefore, if a mechanism is provided that allows you to make a postpay payment without the need to enter a signature or PIN, if both sides use the mechanism in advance, It is possible to leave the medical institution when the medical treatment is completed (or when the medicine is received) without performing accounting (without checking the amount).
If such a mechanism is provided, the waiting time at the medical institution can be greatly reduced, the concentration of work at the medical institution can be avoided, and various problems relating to the handling of cash at the accounting window can be solved.

  The present invention has been made in view of such circumstances, and is a payment system and payment method for the self-payment of medical insurance that can be paid in a post-payment without the need to input a signature or a personal identification number, and a computer program therefor The purpose is to provide.

  In order to solve the above-mentioned problems, the medical insurance self-payment payment system according to the present invention registers a target person of a service for changing the payment of the medical insurance self-payment to the insured of the medical insurance requested by the medical institution. Target insured person registration means, reading means for reading the identification information from the storage means in which the identification information of the insured person is recorded, and the insured person registered by the target insured person registration means based on the read identification information Qualification authentication means for confirming whether or not the insured person has been incurred, and reimbursement requesting means for requesting payment of the medical insurance self-payment for the insured person based on the confirmation result by the qualification authentication means; , A reimbursement amount determining means for processing the amount charged by the reimbursement request means, and a reimbursement request for the self-payment of the medical insurance from the medical institution Characterized by comprising a insured billing determination means for determining a billing as reimbursement amount payments advance against.

  Further, in the present invention, the reimbursement requesting means includes a confirmation result by the qualification authentication means and a confirmation result as to whether or not the insured is willing to receive a payment replacement service for the medical insurance self-payment. Based on the above, it is determined whether to charge or not.

  Further, in the present invention, the insured claim amount determining means satisfies the condition that the medical insurance self-payment for the insured person receives a special payment of additional benefits and high medical expenses from the insurer of the medical insurance. If it is determined that the condition is satisfied, the payment is charged to the invoiced party on behalf of the insured person, and the insured person is based on the requested amount. The amount corrected in this way is determined as a billing amount as a compensation amount.

  Further, the payment method for the self-payment of the medical insurance in the present invention includes a process of registering a person who is subject to a service for changing the payment of the self-pay for the medical insurance to the insured of the medical insurance requested from the medical institution, A process of reading the identification information from the storage means in which the identification information of the person is recorded, and whether or not the insured person is an insured person registered by the target insured person registration means based on the read identification information. A process of confirming, a process of requesting payment for the insured's self-payment for the insured person based on the confirmation result, a process of performing a payment process for the amount of the claim, a process from the medical institution And a step of determining a claim amount as a reimbursement amount of the advance payment amount with respect to the advance payment request amount for the medical insurance self-payment.

  In addition, the present invention is a computer program used in a payment system that pays for the medical insurance self-payment by post-payment, and establishes the payment for the medical insurance self-pay for the insured person of the medical insurance requested by the medical institution. A process of registering a target person of the service to be replaced, a process of reading the identification information from the storage means in which the identification information of the insured person is recorded, and the insured person registers the target insured person based on the read identification information A process for confirming whether or not the person is an insured registered by the process, a process for requesting payment of the medical insurance self-payment for the insured person based on the confirmation result, and And processing for determining a billing amount as a reimbursement amount of the reimbursement payment amount with respect to the reimbursement payment amount of the medical insurance self-payment from the medical institution. Characterized in that to execute up by at least one computer.

According to the present invention, the qualification authentication means confirms that the insured person is a valid target person for the reimbursement service for the self-payment of the medical insurance. For example, it is necessary to input a signature or a password. Instead, you can pay by postpay. Moreover, since the reimbursement request means requests the insured person to pay for the self-payment of the medical insurance, it is possible to easily provide the insurer with payment information for the self-pay of the medical insurance. it can.
In addition, according to the present invention, it is possible to provide convenience to the patient by realizing a postpaid service by the storage means that records the identification information of the insured person, the waiting time at the accounting counter is eliminated, and at the time of consultation There is no need to facilitate cash, and no deposit is required for admission. In addition, cash handling at the accounting counter is also reduced in medical institutions, and furthermore, it is possible to prevent omission of collection for the self-payment.

Hereinafter, a payment system for self-payment of medical insurance in the embodiment of the present invention will be described in detail with reference to the drawings.
FIG. 1 shows the flow of communication between a medical institution and a patient when the payment renewal service is not used. As shown in FIG. 1, when a medical practice is provided in a medical institution (step S500), a claim for medical examination is generated in the medical institution, and at the same time, a patient who has received the medical examination has a debt for medical care. Occurs (step S501).
The amount of debt is determined only after the accounting process is performed in the medical institution (step S502) and the amount of medical fee is determined (step S503). Accordingly, during this time (steps S502 to S504), the patient is kept waiting at the medical institution until the billing process is completed.
The patient confirms the confirmed billing amount (step S505), and the debt is finally paid when the payment is completed.

On the other hand, FIG. 2 and FIG. 3 show the flow of exchanges between a medical institution and a patient, a payment institution, and an insurer when using a payment renewal service.
As shown in FIG. 2, the patient first makes a service use application at a payment reimbursement organization or a medical institution (step S510). The payment reimbursement organization accepts the service use application and performs the service use registration for the patient (step S511). In addition, when an application for use of a service provided by a payment institution is made through a medical institution, the payment institution performs service use registration for the patient based on the service use application accepted by the medical institution (step S513, S512).
In this way, by registering the use of the payment advancement service in advance or prior to use, the patient receives a declaration of the use of the payment advancement service (step S520), and the insured by the personal authentication card After confirming the user's qualification (step S521) and service availability confirmation (steps S522, S523), the payment reimbursement organization starts providing the service to the registered patient (step S524).

That is, when a medical practice is provided in a medical institution (step S525), a claim for medical care is generated in the medical institution, and at the same time, a debt for medical care is generated in a patient who has received the medical care (step S525). S526).
As in the case shown in FIG. 1, the debt amount is determined only after the accounting process is performed in the medical institution (step S502) and the medical fee amount is determined (step S528).
However, when using the payment renewal service, since it is confirmed on the medical insurance payment system that the billing process for the medical practice is performed collectively for each predetermined period, during this time (steps (S528 to S529)) There is no need to wait at the medical institution until the billing process is completed, and it is possible to leave the medical institution with the debt amount being uncertain (step S527).

That is, a person who is subject to a service for changing the payment of the medical insurance self-payment to the insured of the medical insurance requested by the medical institution is registered (step S512), and the insured person at the time of the medical examination receives the medical care It is confirmed whether or not there is an intention to receive a payment replacement service for the insurance self-payment, and an insured who has been confirmed to have an intention to receive the payment replacement service is excluded from the claims processing target person.
Specifically, for example, a table of a billing process list for an insured person who uses the payment reimbursement service and a table of a billing process list for an insured person who does not use the payment reimbursement service are provided separately. In the system, basically, when the insured's claim record is managed on the table of the claim processing list for the insured who does not use the payment renewal service, and the confirmation result of the intention to use the service is input And deleting the invoiced claims record of the insured person from the billing process list table for the insured who does not use the payment reimbursement service, and the invoiced process list table for the insured person using the payment reimbursement service. Just write it.
Therefore, by using the payment reimbursement service, the insured person can return without waiting for the settlement of the accounting after reception, and the convenience of the patient can be improved.

For the insured's self-pay portion of the insured who is excluded from this claim processing person, for example, the payment for the self-payment of the self-pay portion of the medical insurance is billed to the payment institution for a month, and Get paid.
Therefore, since the payment reimbursement organization reimburses the patient's receivables for a certain period of time and charges the service user to the receivables that have been transferred at a later date and charges the service user, the handling of cash can be reduced. An effect is obtained.

The usage fee for the payment renewal service is charged based on the number of uses, for example, as a compensation for eliminating the accounting waiting time. Then, for example, when the sum of the amount of receivables for one month (medical insurance self-payment + service usage fee) is confirmed (step S530), a billing process is performed (step S531), and the confirmed billing amount is set to the service user. (Step S531), and when the payment is completed, the debt is finally paid (step S532).
It should be noted that a billing / reception proxy service (steps S540 to S548 in FIG. 3) regarding additional benefits or refund of high-cost medical expenses may be performed to offset a part of the transferred receivables.
Then, the service user is billed together with the service usage fee for the portion of the transferred residual credit that offsets a portion of the transferred receivable (medical insurance self-payment) (step S550). In this case as well, the service user confirms the confirmed billing amount (step S551), and this debt is finally paid when the payment is completed (step S552).
With this configuration, collection from a service user by assigning a claim to a third party, reimbursement payment, a collection request, or the like is also possible based on a prior contract between related parties.
In addition to charging for the service user, the medical institution may be charged as a system basic usage fee for accounting service concentration avoidance and cash handling reduction services.

The above flow will be described with reference to time-series flowcharts shown in FIGS. 4 and 5. When using the payment renewal service, the use of the payment renewal service is declared at the time of acceptance.
After confirming the qualification of the insured person at the terminal on the hospital side, an inquiry about the availability of the payment renewal service is made to the registration DB of the payment reimbursement organization, and the qualification confirmation is made to the personal authentication DB . When the payment reimbursement service is used, there is no need to pay for the insured after the checkup, so there is no waiting time for checkup, and it is possible to go home after confirming the end of the checkup.
As described above, according to the medical insurance payment system of the present embodiment, the target person of the service that replaces the payment of the medical insurance self-payment for the insured person of the medical insurance requested from the medical institution is registered, and The insured person confirms whether the insured is willing to receive the payment reimbursement service for the medical insurance self-payment, and confirms that the payment reimbursement confirmation means is willing to receive the payment renewal service. Are excluded from the charge processing person.
Therefore, by using the payment renewal service, the insured person can return without waiting for the settlement of the accounting after the consultation, and the effect of improving the convenience for the patient can be obtained.

  As described above, in the present invention, since the insured person is confirmed to be a valid target person for the reimbursement service for the self-payment of the medical insurance by the qualification authentication means, for example, input of a signature or a password You can pay by postpay without needing. In addition, since the reimbursement request means requests the insured person to pay for the self-payment of the medical insurance, payment information for the self-payment of the medical insurance can be easily provided to the insurer. . In addition, providing post-payment services using a storage means (personal authentication card) that records the insured's identification information can provide convenience to patients, eliminate waiting times at the accounting counter, and provide cash at the time of medical examination. There is no need to facilitate hospitalization, and there is no need for a deposit at the time of hospitalization. Furthermore, cash handling at the accounting counter is also reduced in medical institutions, and furthermore, it is possible to prevent the collection omission of self-pay.

In addition, according to the above-described embodiment of the present invention, the use of the replacement service is determined by the personal authentication card. However, the medical card 1 is recorded by recording the unique number recorded on the personal authentication card on the medical card. It is also possible to realize the system with a single sheet.
In addition, the above-described procedures executed by each of the insured person use registration means, identification information reading means, qualification authentication means, advance payment request means, advance payment amount determination means, and insured claim amount determination means are read by a computer. It is possible to realize the payment system for the self-payment of the medical insurance according to the present invention by recording on a possible recording medium, causing the computer system to read and execute the program recorded on the recording medium. The computer system here includes an OS and hardware such as peripheral devices.

Further, the “computer system” includes a homepage providing environment (or display environment) if a WWW system is used.
The program may be transmitted from a computer system storing the program in a storage device or the like to another computer system via a transmission medium or by a transmission wave in the transmission medium. Here, the “transmission medium” for transmitting the program refers to a medium having a function of transmitting information, such as a network (communication network) such as the Internet or a communication line (communication line) such as a telephone line.
The program may be for realizing a part of the functions described above. Furthermore, what can implement | achieve the function mentioned above in combination with the program already recorded on the computer system, and what is called a difference file (difference program) may be sufficient.

  The embodiment of the present invention has been described in detail with reference to the drawings. However, the specific configuration is not limited to this embodiment, and includes design and the like within the scope not departing from the gist of the present invention.

Normal medical institution and patient interaction flowchart Flow chart of exchange between medical institution and patient when using payment renewal service Flow chart of exchange between medical institution and patient when using payment renewal service Flowchart when the exchange between the medical institution and patient shown in FIGS. Flowchart when the exchange between the medical institution and patient shown in FIGS.

Claims (5)

Target insured person registration means for registering a target person of a service for changing the payment of medical insurance self-payment for insured persons of medical insurance requested by a medical institution;
Reading means for reading the identification information from the storage means recording the identification information of the insured;
Qualification authentication means for confirming whether the insured is registered by the target insured person registration means based on the read identification information; and
Based on the confirmation result by the qualification authentication means, a reimbursement requesting means for requesting payment for the self-payment of the medical insurance for the insured person,
A reimbursement amount determination means for processing the amount charged by the reimbursement request means;
Insured claim amount determination means for determining a claim amount as a reimbursement amount of the advance payment amount for the advance payment amount of the medical insurance self-payment from the medical institution Minute payment system. The reimbursement request means is
Based on the confirmation result by the qualification authentication means and the confirmation result on whether or not the insured is willing to receive a payment reimbursement service for the medical insurance self-payment, a decision is made as to whether or not to charge. The medical insurance self-payment payment system according to claim 1. The insured claim amount determining means is:
When it is determined that the medical insurance self-payment for the insured satisfies the conditions for receiving additional benefits and special payments for high-cost medical expenses from the medical insurance insurer, etc. For the insured person, he / she shall be charged for the payment to the invoiced party, and for the insured person, the amount corrected based on the invoiced amount shall be determined as the invoiced amount. The payment system for self-pay of medical insurance according to claim 1 or 2. The process of registering the person eligible for the service to replace the payment of the medical insurance self-payment for the insured of the medical insurance requested by the medical institution;
A process of reading the identification information from the storage means recording the identification information of the insured;
Confirming whether the insured is the insured registered by the target insured person registration means based on the read identification information;
Based on the confirmation result, requesting payment of the insured for the self-payment of the medical insurance;
A process of performing a payment process on the invoiced amount;
A method of determining a charge amount as a reimbursement amount of the advance payment amount for the advance payment amount of the medical insurance self-payment from the medical institution. A computer program used in a payment system that pays for medical insurance self-pay by postpay,
A process of registering a person eligible for a service that replaces the payment of the medical insurance self-payment for the insured of the medical insurance requested by the medical institution;
A process of reading the identification information from the storage means in which the identification information of the insured is recorded;
A process for confirming whether or not the insured person is an insured person registered by the target insured person registration means based on the read identification information;
Based on the confirmation result, a process for requesting payment of the medical insurance self-pay for the insured person,
Processing to perform payment processing on the billed amount;
A program that causes at least one computer to execute a process of determining a charge amount as a reimbursement amount of the advance payment amount with respect to the advance payment amount for the medical insurance self-payment from the medical institution.

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