AI Medical Insurance Flight Inspection & Hospital Risk Control Solution

Functional Overview

Based on Huawei Ascend computing power and the DeepSeek large model, combined with Chinasoft International's professional expertise in medical insurance supervision informatization, we build the "Hospital-end Medical Insurance AI Risk Control Appliance" solution. It enables full-process intelligent control of medical insurance funds at the hospital end before, during, and after events, forming a three-tier prevention and control system of "risk alerts, doubt analysis, collaborative implementation", comprehensively helping hospitals improve the quality and efficiency of medical insurance fund management.

Customer Pain Points

  • Stricter policies: From the "Regulations on the Supervision and Administration of the Use of Medical Security Funds" to normalized flight inspections, policies explicitly require medical institutions to establish a "full-process intelligent monitoring system"; traditional manual sampling and post-event accountability models can no longer meet regulatory requirements.
  • High flight inspection pressure: Flight inspections use "four no's and two direct" surprise methods, combined with big data screening and intelligent monitoring technologies, to accurately lock down illegal and non-compliant behaviors.
  • Frequent violations: For most hospitals, about 60% of issues arise in charging, such as duplicate charges, charges exceeding standards, substitution of drugs, and excessive diagnosis and treatment, which are high-incidence problems urgently needing resolution. Under traditional audit models, manual sampling coverage is less than 5%, and a large amount of medical insurance denied payments are recovered.
  • Slow response: There is a lack of effective intelligent identification and pre-event interception capabilities for new types of violations under DRG/DIP payment reform (such as upcoding, low-code high-set, etc.).

Solution Advantages

  • Upgraded risk prevention and control: AI accurately identifies 100+ high-risk scenarios, improving violation detection rate by over 40%. Real-time interception of violations during events reduces medical insurance denied payment disputes by 60%.
  • Leap in audit efficiency: Single-case audit time is shortened from minutes to milliseconds, supporting 100,000+ cases per day, and reducing labor costs by over 50%.
  • Full-process compliance assurance: Built-in configurable rule library, dynamically adapts to policy changes, AI provides traceable audit trails, ensuring flight inspections and audits are transparent and verifiable, reducing legal dispute risks.
  • Data-driven decision-making: Through intelligent analysis dashboards, provide insights on violation trends, disease-specific cost distributions, etc., to assist refined management.

Architecture Diagram

Architecture Diagram