Basic Claim Assessment for Day-In-Hospital Benefits

Name: Basic Claim Assessment for Day-In-Hospital Benefits
Rating: 5.0 (1 reviews)

Overview of how to assess these claims, obtain documentation and interpret it to combat insurance fraud and abuse

Created byLinda van der Westhuizen

Last updated 1/2024

English

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

Course content

8 sections • 22 lectures • 1h 15m total length

Introduction0:58
Hello!

Its so great that you have joined this course and I hope that this video will give you some insight into my credentials and assure you that you are in good hands!

You can download a copy of the slides here and use them for note making or to refer back to at a later time
Overview and why important claim assessment is required1:59
Remember:
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
Understanding fraud and current fraud trends3:07
There is always a reason that fraud or abuse is committed, mitigate the risk of having a reason and you lessen the likelihood of fraud or abuse occurring

Introduction1:15
A quick video to take you through why a second version exists and to explain how it ties in with the previous videos
The reasons we need to be effective to be effective in assessing claims1:31
The claims process - Step 1, 2 and 37:37
In the first 3 steps we cover the very basics that should be covered when a claim lands on your desk. These steps are often rushed or left out which can lead to information and red flags being missed.
The claims process - Step 4 and 54:01
The claims process - Step 64:56
In this video we take a quick dive into the analysis of the hospital account - the most valuable tool for assessors. This document can corroborate all the details on your claim form and also assist in compiling a timeline of the treatment that the insured received during the admission period.
The claims process - Steps 7, 8 and 98:48
In these steps we use the skill of critical analysis and you may find that your assessments becomes an investigation if you are not able to clear up your red flags.
The claims process - Step 102:42
This is the last step in the process and where all the work you have done on the claim really comes together. In answering the questions outlined in this video you can compile the conclusion of your report and also begin a defense for repudiation of the claim or recommend an approval of the claim
Extra resources0:09

Requirements

Understanding of insurance claims processing

Description

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.

PLUS!

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

Basic Claim Assessment for Day-In-Hospital Benefits

What you'll learn

Explore related topics

Course content

Introduction to Version 1.03 lectures • 6min

Case studies: Falsification of admissions and document tampering1 lecture • 6min

SOMETHING EXTRA: Parastatal investigation case study1 lecture • 8min

The process of assessing claims for day-in-hospital benefits6 lectures • 17min

SOMETHING EXTRA: Red flagging COVID 19-related admissions1 lecture • 6min

Red flag check list1 lecture • 2min

Claims assessment Version 2.08 lectures • 31min

Closing notes1 lecture • 1min

Requirements

Description

Who this course is for: