Basic Claim Assessment for Day-In-Hospital Benefits
What you'll learn
- Effectively assess insurance claims for hospitalization
- Understand how and why fraud is committed
- Equipped with a proven claims assessment process
- Verification of admission and treatment
- Verification of hospitalization
- EXTRA: Assessing COVID 19-related claims
- EXTRA: Syndicate activity within in medical insurance fraud
- Understanding of insurance claims processing
Are you a claims assessor that works with or wishes to work with medical / health related products?
Do you want to broaden your knowledge base about or gain insight into medical / health related claims?
Specifically how to assess claims that for a benefit that will pay out for every day that the insured client is admitted?
This is the course for you!
This course is designed to equip you with insight into how to assess and therefore red flag and verify these types of claims and ultimately to prevent the payment of potentially fraudulent claims by learning about:
Why effective claims assessment is necessary
The reasons that fraud is committed
Current trends in fraud related to the above mentioned insurance products
How to verify diagnosis, treatment and hospitalizations
Using medical documents as an integral part of the claims process
I also provide case studies of actual, real life admissions I have reviewed and giving expert opinion on as well as investigations I have performed in the past to demonstrate how to use the above knowledge to assess your claims effectively and red flag suspicious claims and potentially form a basis for repudiation or rejection of the claim
Claims assessors are the first line of defense against insurance fraud, they are the gate keepers that prevent abuse of insurance products and detect fraud by spotting discrepancies and asking questions. The skill and ability to do this can be learned as your deepen your insight into the assessment of insurance claims
This will help you in your career and build your confidence as a medical claims assessor and allow you to stand out among your peers.
I have added some EXTRA videos for enhanced and deepened learning to this course to take your knowledge to the next level. These include:
1. Extra: Criteria for red flagging claims for admissions related to COVID 19
2. Extra: A discussion on a previous parastatal investigation related to massive medical fraud including document tampering and falsification of admissions
Who this course is for:
- Claim assessors
- Insurance industry
- Public adjustors
- Claim adjustors
- Medical investigators
South African based Medical & Healthcare Fraud & Syndicate Investigator and student of the law and psychology. I have expertise in the performing of expert assessments on medical claims for the insurance industry as well as leading and assisting in ad hoc syndicate investigations for insurers and parastatal entities.
I have worked in many areas including risk mitigation, policy review, ombudsman matters, public adjusting and claim adjusting.
I have a passion for teaching the craft of forensics and am excited to be sharing my expertise with those who want to upskill and broaden their own knowledge in claims processing and investigations.