中国农村卫生事业管理2025，Vol.45Issue(4)：292-296,5.DOI:10.19955/j.cnki.1005-5916.2025.04.011
大数据背景下医保欺诈基金监测研究
Fund monitoring of medical insurance fraud in the context of big data
摘要
Abstract
Objective To reduce and mine the collected data related to medical insurance fraud,iden-tify the abnormal data,find out the problems existing in the current fund monitoring,and put forward sugges-tions for improving the monitoring.Methods Relevant data were collected through field investigation,and the t-SNE algorithm and KNN algorithm were used to reduce the data and mine the abnormal data,respectively.Results In the data of hospitalization expenses of 6,292 patients,41 anomalies were identified;Meanwhile,it was also found that there were some problems in the current monitoring of medical insurance fraud,such as the relatively rough setting of"two databases"(namely,medical insurance knowledge database and medical insur-ance regulation database),too much abnormal data mining,imperfect intelligent monitoring data,and the a-daptability of the monitoring system to be improved.Conclusions It is necessary to start from optimizing the setting of the"two databases",strengthening data collection and integration,improving data analysis capabili-ties,and expanding remote intelligent monitoring,so as to improve the monitoring of medical insurance fraud.关键词
大数据/社会医疗保险/欺诈骗保/基金监测Key words
Big data/Social medical insurance/Fraud/Fund monitoring分类
医药卫生引用本文复制引用
詹长春,索丽..大数据背景下医保欺诈基金监测研究[J].中国农村卫生事业管理,2025,45(4):292-296,5.基金项目
国家社会科学基金项目(19BGL200) （19BGL200）
