Last updated 4/2022
MP4 | Video: h264, 1280x720 | Audio: AAC, 44.1 KHz
Language: English | Size: 314.50 MB | Duration: 0h 44m
Overview of how to assess these claims, obtain documentation and interpret it to combat insurance fraud and abuse
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
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 necessaryThe reasons that fraud is committed Current trends in fraud related to the above mentioned insurance products How to verify diagnosis, treatment and hospitalizationsUsing medical documents as an integral part of the claims processI 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 claimClaims 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
Overview
Section 1: Introduction
Lecture 1 Introduction
Lecture 2 Overview and why important claim assessment is required
Lecture 3 Understanding fraud and current fraud trends
Section 2: Case studies: Falsification of admissions and document tampering
Lecture 4 Case studies
Section 3: SOMETHING EXTRA: Parastatal investigation case study
Lecture 5 Parastatal investigation
Section 4: The process of assessing claims for day-in-hospital benefits
Lecture 6 Introduction
Lecture 7 Verifying the diagnosis
Lecture 8 Verifying the treatment received
Lecture 9 Verifying hospitalization
Lecture 10 Determining whether the length of admission was appropriate
Lecture 11 Pre-existing conditions & non-disclosure
Section 5: SOMETHING EXTRA: Red flagging COVID 19-related admissions
Lecture 12 Criteria for red flagging claims for admissions related to COVID 19
Section 6: Red flag check list
Lecture 13 Summary of red flags
Section 7: Closing notes
Lecture 14 Thank you
Claim assessors,Insurance industry,Public adjustors,Claim adjustors,Medical investigators
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