About the Course

Health insurance claims are central to the financial sustainability, service quality, and public confidence of insurers, health funds, third-party administrators, and healthcare providers. Weak claims controls can lead to delayed settlements, inaccurate payments, member dissatisfaction, provider disputes, regulatory exposure, and significant financial leakage. At the same time, increasingly complex benefit designs, digital claims channels, changing clinical practices, and organized fraud schemes require claims teams to combine technical adjudication skills with stronger analytical and investigative capabilities.

The Health Insurance Claims Management and Fraud Detection program provides a practical framework for managing the full claims lifecycle while strengthening payment integrity. The course covers claims intake, eligibility and coverage validation, clinical coding compliance, adjudication controls, fraud-risk typologies, provider profiling, claims analytics, pre-payment and post-payment review, investigation case management, recovery processes, compliance reporting, and continuous improvement. It also introduces operational applications of artificial intelligence and explainable anomaly detection without requiring programming skills.

Through realistic claim files, coding-validation exercises, provider-risk scorecards, fraud-indicator matrices, investigation simulations, and dashboard development, participants will learn how to identify suspicious patterns, make defensible payment decisions, document findings, and escalate cases appropriately. The program emphasizes practical tools that can be adapted to public health insurance schemes, private insurers, managed-care organizations, hospital networks, and third-party administrators.

Target Participants

• Health insurance claims officers
• Claims examiners
• Medical assessors
• Utilization-review personnel
• Fraud analysts
• Payment-integrity specialists
• Special investigation unit officers
• Internal auditors
• Compliance officers
• Risk managers
• Finance officers
• Healthcare administrators
• Provider-relations teams
• Clinical coders
• Data analysts
• Legal officers
• Managers responsible for claims operations or fraud-control programmes

Prerequisites: Participants should have basic familiarity with health insurance benefits, claims processing, provider billing, or healthcare operations.

What You Will Learn

By the end of this course the participants will be able to:

• Map the health insurance claims lifecycle and identify control weaknesses, delays, and leakage points
• Validate member eligibility, benefit coverage, medical necessity, provider status, and claim documentation
• Apply clinical coding and billing-validation techniques to detect errors, upcoding, unbundling, duplicate claims, and phantom billing
• Conduct consistent claims adjudication using clear decision rules, authorization controls, exception handling, and audit trails
• Develop fraud indicators, provider-risk profiles, utilization benchmarks, and anomaly-detection review procedures
• Design effective pre-payment and post-payment review programs that strengthen payment integrity and recovery outcomes
• Manage investigations using structured case files, evidence standards, interview techniques, referral protocols, and corrective actions
• Present claims and fraud findings through dashboards, executive reports, compliance communication, and improvement plans

Course Duration

• Classroom – 5 Days
• Online – Available

Course Outline

Health Insurance Claims Fundamentals

• Health insurance operating models
• Payer, provider, member, broker, and regulator roles
• Benefit design and claims obligations
• Claims-risk exposure points
• Claims-process mapping exercise

Claims Intake

• Claim submission channels
• Data capture requirements
• Completeness checks
• Duplicate detection
• Claim-intake checklist exercise

Eligibility Verification

• Member identification
• Policy status confirmation
• Waiting periods and exclusions
• Dependant and beneficiary validation
• Eligibility decision simulation

Coverage Validation

• Benefit limits
• Pre-authorization requirements
• Medical necessity review
• Network and referral rules
• Coverage-validation case exercise

Clinical Coding Compliance

• ICD-10 coding principles
• Procedure and tariff coding
• Upcoding and unbundling indicators
• Modifier and diagnosis inconsistencies
• Coding-validation workshop

Claims Adjudication

• Adjudication rules
• Pay, deny, pend, and query decisions
• Authorization and segregation controls
• Exceptions and appeals
• Adjudication file review

Fraud Risk Typologies

• Provider fraud schemes
• Member fraud schemes
• Collusion and identity misuse
• Pharmacy and telehealth abuse
• Fraud-indicator matrix exercise

Provider Risk Profiling

• Utilization benchmarking
• Peer-comparison ratios
• Frequency and severity metrics
• Provider-risk scoring
• Risk-scorecard workshop

Claims Data Analytics

• Claims-data preparation
• Trend and outlier analysis
• Rules-based anomaly detection
• AI-assisted risk flags and explainability
• Claims-analytics practical

Payment Integrity Controls

• Pre-payment review
• Post-payment audit
• Overpayment recovery
• Control performance indicators
• Payment-integrity workflow design

Investigation Case Management

• Case triage and prioritization
• Evidence collection
• Interview and statement procedures
• Referral, sanctions, and recovery actions
• Investigation-case simulation

Compliance Reporting

• Claims performance metrics
• Fraud-loss measurement
• Management dashboards
• Regulatory and executive communication
• Capstone payment-integrity presentation

Training Approach

The course uses a competency-based methodology combining expert facilitation, realistic health-insurance case studies, claim-file reviews, eligibility and coverage simulations, clinical-coding validation, adjudication exercises, fraud-pattern diagnostics, provider-risk scoring, claims-data analysis, pre-payment and post-payment review design, investigation-case workshops, and dashboard development.

Participants progressively create a practical claims-control toolkit comprising a claims-review checklist, fraud-indicator matrix, provider-risk scorecard, investigation case-file structure, payment-integrity dashboard, and workplace improvement plan.

Certification

Upon successful completion of this course, participants will be issued a certificate.

Tailor-Made Course

We can also do this as a tailor-made course to meet organization-wide needs.