Health Insurance Fraud Fundamentals

Overview

Health insurance fraud is a growing concern within healthcare financing systems and can significantly impact insurers, healthcare providers, and policyholders. Fraudulent practices such as false claims, inflated medical bills, and misuse of health insurance benefits can lead to substantial financial losses and undermine trust in the healthcare insurance system.

This course provides a practical introduction to the principles and strategies used to detect and prevent fraud in health insurance operations. Participants will develop an understanding of common health insurance fraud schemes, the warning signs that may indicate fraudulent activities, and the procedures used to investigate and manage suspected fraud cases.

The programme also explores the importance of strong internal controls, claims verification procedures, and collaboration between insurers and healthcare providers in strengthening fraud prevention efforts.

Who Should Enrol

This course is designed for professionals involved in health insurance operations and fraud prevention, including:

• Health insurance claims officers and administrators
• Insurance underwriters handling health insurance policies
• Fraud investigators and compliance officers
• Insurance agents and intermediaries involved in health insurance distribution
• Healthcare administrators and provider network staff
• Professionals seeking to strengthen their knowledge of health insurance fraud prevention

What You Will Learn

Participants will gain practical knowledge and understanding of:

• The nature and impact of fraud in health insurance systems
• Common health insurance fraud schemes and practices
• Indicators and warning signs of fraudulent medical claims
• Claims verification and investigation techniques
• Internal control mechanisms used in fraud prevention
• Best practices for detecting and managing health insurance fraud risks

Learning Pathway

This course forms part of the IIEA E-Academy Learning Pathway Framework™ for Advanced Insurance Professionals, designed to strengthen technical expertise across key areas of insurance practice.

Certification

Participants who successfully complete the course requirements will receive a Certificate of Achievement recognising their successful completion of the programme.

This course complements other fraud prevention programmes such as:

• Insurance Fraud Essentials
• Insurance Fraud Prevention Fundamentals
• Life Insurance Fraud Prevention Fundamentals

and helps build specialised capability in identifying and managing fraud risks within health insurance operations