He Yaoshi Medical Insurance Drug Audit

Audit Pain Points

Before insurance settlement, manual checks of orders, medical records, insurance catalogs, and audit rules can miss issues such as off-label use, duplicate billing, split billing, dose or course violations, unnecessary consumables, and unsupported care. Source files are often PDF, Word, or image attachments, while diagnosis, ICD codes, DRG groups, payment restrictions, and charge standards are scattered across fields, making line-by-line comparison slow and hard to standardize.

How the Skill Works

The skill breaks audit into engineering steps: maintain references/medical_catalog.json for drug, consumable, and service catalogs; store normalized rules in references/audit_rules.json; parse uploaded records to extract case ID, diagnosis, ICD-10, procedures, charges, order details, and DRG codes; run rule matching to flag off-label use, duplicate billing, excessive use, consumable misuse, DRG mismatches, ICD errors, and other issues; then generate an Excel issue list and a Word report with project details, descriptions, severity, and remediation advice.

Scope and Caveats

It is better suited for pre-settlement review, department self-checks, and case retrospectives, not for replacing payer final adjudication or legal determinations. Image OCR and PDF extraction may still require manual review of key fields, and insurance catalogs and rules should be refreshed according to region, fiscal year, and catalog update cycles.