• Health Insurance Underwriters and Claims Practitioners.
• Loss Adjusters, Third Party Administrators and Claims Investigators.
• Insurance professionals including intermediaries seeking to enhance their skills in detecting and managing health insurance fraud.

At the end of the programme, participants should be able to:

• Grasp the concepts of fraud, abuse, and leakage in insurance.
• Identify and analyze various fraud types, address data challenges, and understand regulatory aspects in fraud detection.
• Recognize motivations and red flags for soft and hard fraud.
• Develop critical thinking for improved risk management and align theory with practical application.
• Gain hands-on knowledge through case studies.
• Learn to create and implement fraud management algorithms and hierarchies.

• Overview of Health Insurance and vulnerability to fraud.
• Challenges in managing Health Insurance Fraud.
• Disease progression: acute and chronic ailments, preventive care, and discharge planning.
• Medical Necessity and Appropriateness in treatment.
• Medical Management based on Standard Treatment Guidelines.
• Insurance Fraud from a Hospital/Medical Provider perspective.
• Interpretation of hospital documents.
• Rational management of acute ailments and fraud prevention.
• Emergency hospitalization conditions: fever, gastroenteritis, respiratory distress, trauma, and chronic ailments.
• Musculoskeletal disorders and claim assessment.
• OPD, Daycare, and IPD treatment differentiation.
• Substance Abuse: Nicotine and Alcohol.
• Effective Claims Management as a Profit Driver.
• Managing specific ailments like acute infections, diabetes, hypertension, etc.
• Final steps in fraud detection and legal aspects.
• Submodules on respiratory, renal, and hepatic ailments in fraud prevention.

Dr. C H Asrani, a pioneer in medical audit and insurance risk management, brings 46 years of experience. With extensive work in insurance training globally and involvement with National Health Authority and The World Bank, Dr. Asrani specializes in underwriting insights, claim adjudication, and fraud prevention. His cloud-based solutions and X-Claims tool are at the forefront of innovation in the insurance industry.

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Full Course Fee: S$1,308.00 (incl. of 9% GST)