Healthcare Insurance Fraud Management

Overview

Health insurance providers, managed care organizations, and other healthcare stakeholders are increasingly tasked with achieving more on shrinking budgets. This places premium on strategies that combat and deter financial effects of healthcare fraud. With Health Insurance Fraud Management training you will gain valuable expertise in detecting, deterring, and reducing healthcare fraud and to help you do your job even better.

Purpose

This two-day in-house training will help participants gain valuable expertise in detecting, deterring, and reducing health care fraud.

Accreditation

This course is accredited by the International Fraud Training Group (IFTG) of USA. The International Fraud Training Group (IFTG) is a full-service Insurance training and consulting firm providing training and compliance services throughout the World. It is one of the largest privately-held companies in the industry, offering structured programs for insurance carriers, self-insured’s, and third-party administrators. The Insurance Institute of East Africa is the exclusive provider of IFTG’s fraud training programs in East Africa.

Suitability

This course is suitable for: -

• Medical Underwriters
• Claims Analysts
• Case Managers
• Sales Teams (Business Development)
• Agents and Brokers
• Loss Adjusters
• Risk and Compliance Officers
• Call Centre and Customer Service Teams
• Regulatory Personnel
• Fraud Examiners
• Management Team

What is Covered

Day One

Introduction to Insurance Fraud

This course will provide the medical insurance professional with an overview to Insurance Fraud, including the effects of insurance fraud, the growing statistics of insurance fraud, examples and current fraud schemes as well as their consequences, the efforts to reduce insurance fraud and the role that you play to combat fraud. Participants will learn about successful investigative techniques that can be used by themselves or the field investigators. It will provide knowledge on what outside field investigators can do, what they need to do, how to plan for the investigation and learn the types of investigations that can be conducted. This course also includes fraud detection tactics and red flag indicators for insurance fraud.

Healthcare Insurance Fraud

This course will provide the participants with very detailed knowledge of healthcare insurance fraud. In this training, participants will learn how health care fraud works. We’ll examine a wide array of fraudulent schemes, perpetrated by a variety of actors (health care providers, professional criminals, consumers, agents and brokers and others) and involving different types of health care services and different health insurance coverages. Then we’ll learn how these schemes are combated—the steps insurance company personnel take to detect when fraud is happening, investigate cases, and (perhaps most important) deter future fraud. Completion of this training will provide participants with an all inclusive understanding of the scope of this problem, ranging from the simplest situations to complex and sophisticated healthcare insurance fraud crimes and compare the different ways fraud schemes work and where they often occur.

Dental Fraud

This module will provide the insurance professional with knowledge of healthcare fraud and in particular, what Dental Fraud is. They will have an overview of terminology and procedures. They will learn ways to identify the frauds, how to investigate the frauds. The module will also provide true examples of dental fraud and how it is being perpetrated within the insurance industry and how to prevent them.

Day Two

Healthcare Investigations

This course will discuss how healthcare insurance fraud investigation is carried out and the tools required for conducting an effective investigation since detection is only the beginning of the pursuit of a case of fraud. It will review the use of files and records to shed light on the insurance application, payment histories, and medical records of the insured, relationship with other insurance companies etc. We will also review interview and surveillance as the review of files and records alone does not enable an investigator to determine whether fraud has been committed. This will include planning and conducting interviews, recording interviews, signed statements and affidavits, and actual surveillance.

Collaborative Anti-Fraud Efforts

Insurance company personnel cannot work in isolation to combat fraud. To be effective, they must collaborate with others outside the company. This course will review the collaborative anti-fraud efforts the insurers oath to take including making those who witness fraud firsthand aware of fraud and its costs, working closely with law enforcement, regulatory, and other government agencies engaged in anti-fraud activities, exchanging information with other insurers among others.

Insurer Anti-Fraud Program

There are many actions an insurance company can take against fraud. But for these actions to have the greatest possible impact, they must be coordinated. The best way for an insurer to make sure its employees are working together effectively is instituting a formal anti-fraud program. Participants will learn how this is done and implemented.