Overview
This course provides a detailed exploration of health care fraud, one of the most costly and damaging challenges facing modern health insurance systems. Learners are introduced to the scale of the problem, the core legal definitions of fraud, and the distinctions between fraud, abuse, and waste. The course examines fraudulent schemes across the entire health care ecosystem—including providers, consumers, agents, brokers, and internal insurer staff—showing how misrepresentations, false claims, identity misuse, billing schemes, and organized fraud rings inflate costs and undermine the integrity of health financing. It also highlights the operational vulnerabilities within fee-for-service and capitation payment models, and demonstrates how fraud ultimately increases premiums, burdens taxpayers, and compromises patient safety. Through real-world examples and structured content, learners gain foundational knowledge on how fraud operates, how it is detected, and why robust anti-fraud measures are essential to protecting health insurance systems.
Download BrochureLearning Outcomes
On completion of this course, you should be able to:-
- Define health care fraud, abuse, and waste, and explain the legal and operational distinctions between them using statutory and industry definitions;
- Describe the economic and social impact of health care fraud, including its contribution to rising health care costs and insurance premiums;
- Describe the economic and social impact of health care fraud, including its contribution to rising health care costs and insurance premiums;
- Identify the major categories of health care fraud, including provider fraud, consumer fraud, agent/broker fraud, and internal insurer fraud;
- Explain common provider fraud schemes, such as false claims, upcoding, unbundling, billing for noncovered services, fraudulent diagnoses, DRG manipulation, and kickbacks;
- Recognize consumer fraud schemes, including claim fraud, application fraud, eligibility fraud, medical identity theft/misrepresentation, insurance speculation, and foreign claim fraud;
- Analyse fraud risks associated with payment systems, differentiating the vulnerabilities in fee-for-service versus capitation environments;
- Describe fraud perpetrated by agents, brokers, and insurer employees, including misrepresentation of applications, false advertising, improper replacements, and internal fraud;
- Discuss how organized fraud rings operate, including collusion between providers, consumers, and criminals, and the growing involvement of professional fraud networks;
- Explain major fraud schemes in dental services and prescription drugs, and assess how these activities impact insurer costs, member safety, and overall health system integrity;
- Describe the core elements of a strong insurer Anti-Fraud Program, including prevention, detection tools, internal controls, staff awareness, and reporting procedures;
- Identify fraud indicators and apply practical detection techniques, using data review, pattern analysis, and red-flag assessment across dental, pharmacy, and general health claims;
- Conduct thorough claim file and record reviews, and gather, evaluate, and document evidence accurately to support fraud investigations and decision-making; and
- Demonstrate the importance of collaboration in combating fraud, working with regulators, law enforcement, providers, and industry partners to strengthen prevention, detection, and enforcement.
Who Should Take This Course
- Agents and brokers
- Claims analysts
- Underwriters
- Health insurance provider staff
- Compliance officers
- Corporate counsel
- Federal regulatory personnel
- Fraud examiners
- Legal advisors
- Privacy officers
- State regulatory personnel
- Professionals working in special investigation units (SIUs)
