Introduction
The programme “Claims Verification Procedures and Fraud Detection” develops professional practice in Insurance and Compensation. It connects the subject with workplace challenges by examining existing evidence and practices and choosing methods appropriate to the organization and its available resources.
The learning progresses from claims, dispute, and evidence management to risk assessment, controls, and response, with practical work on fraud prevention, warning sign detection, and integrity protection, procedure analysis and work simplification, insurance, claims, and compensation management. Participants prepare outputs to support workplace application and review the quality and results of implementation.
Learning objectives
- Prepare a documented claim connecting its basis, facts, effects, and supporting documents in an application related to “Claims Verification Procedures and Fraud Detection”.
- Distinguish suspicious indicators and design a professional response that preserves evidence and confidentiality.
- Redesign a procedure to reduce delays and rework while maintaining controls.
- Analyze insurance coverage and a claim process, and document the settlement basis.
- Prepare a risk register connecting causes, consequences, controls, and treatment responsibilities.
Learning areas
1. Claims, Dispute, and Evidence Management
- Analyze the event giving rise to the claim, notice requirements, jurisdiction, and deadlines by referring to the contract and applicable law.
- Prepare a chronology connecting correspondence, instructions, and execution records, distinguishing facts, estimates, and allegations.
- Identify the relationship between the event and its time or financial effects, examining alternative explanations and the data needed to establish causation.
- Draft a claim file explaining the request, its basis, supporting documents, and calculation method, and review consistency and weaknesses before submission.
- Compare negotiation, settlement, and escalation routes according to authority, cost, and time, and prepare a register of lessons and measures to prevent recurring disputes. The application examines a case related to “Claims Verification Procedures and Fraud Detection”.
2. Fraud Prevention, Warning Sign Detection, and Integrity Protection
- Analyze exposure to fraud and conflicts of interest in the process, and distinguish errors, suspicious indicators, and established facts.
- Identify warning signs in transactions, authorities, and data, and design analytical checks that support verification without making accusations.
- Review segregation of duties, approvals, reconciliations, and system permissions, and assess their effectiveness in prevention and detection.
- Define reporting, escalation, evidence preservation, and confidentiality procedures, and review local legal requirements before taking investigative action.
- Prepare a case study covering indicators, additional data required, and a plan for correcting controls and monitoring the response.
3. Procedure Analysis and Work Simplification
- Define the procedure's start, end, owner, inputs, and outputs, and collect data on processing time, waiting, and rework.
- Map the actual workflow between roles, identifying approvals, handovers, bottlenecks, and duplicate data entry.
- Analyze the value added by each step and the controls it provides, and propose combining, removing, or running steps in parallel with reasons for the choice.
- Document the improved procedure with clear authorities, forms, timelines, and standards, and review its effects on beneficiaries and delivery teams.
- Test the procedure on a limited case, measure time, errors, and output quality, and document adjustments and the rollout plan.
4. Insurance, Claims, and Compensation Management
- Read an insurance policy and identify the risk, coverage, limits, exclusions, deductible, and parties, referring to applicable terms and rules.
- Define claim documents, notices, deadlines, and handling procedures, and organize incident data without presuming coverage applies.
- Analyze the relationship between the event, loss, evidence, and estimates, distinguishing confirmed information from matters requiring expertise or further verification.
- Review compensation valuation alternatives, settlement bases, and approval authority, documenting calculations, decision rationale, and available appeal procedures.
- Set indicators for processing time, file accuracy, complaints, and suspicious activity, and improve controls and communication with the claimant during follow-up.
5. Risk Assessment, Controls, and Response
- Define the work context, objectives, and assessment boundaries, and distinguish the risk source, potential event, and effects on results.
- Gather risks from processes, data, past incidents, and interviews with responsible staff, and document causes and existing controls.
- Estimate likelihood and impact using stated criteria, and review control effectiveness to determine residual risk levels.
- Select a response proportionate to the risks, resources, and authority, and specify the owner, deadline, and early warning indicator.
- Test a scenario involving changing circumstances, update the risk register, and present material risks and required decisions to the appropriate authority.
Practical outputs
- A claim file, chronology, document matrix, and impact analysis.
- A matrix of suspicious indicators and controls, and an evidence preservation and escalation checklist.
- An improved procedure map, service profile, and acceptance criteria for implementation.
- An insurance claim file, coverage matrix, and settlement tracking template.
- A risk register, control matrix, and prioritized treatment plan.
Who should attend
- Practitioners, specialists and supervisors whose work relates to the programme subject.
- Managers and teams working in insurance and compensation, according to their practical responsibilities.
- Professionals responsible for applying the outputs of “Claims Verification Procedures and Fraud Detection” within their organizations.
Prerequisites
- Working familiarity with the programme field and the ability to discuss a professional case or challenge.
- Confirm the suitability of your experience and any specialist prerequisites with the Union before participation.
Conclusion
The programme “Claims Verification Procedures and Fraud Detection” brings together concepts, case review and a practical application. Participants prepare steps that can be adapted to their responsibilities and organizational resources, with an indicator to follow application and review results after returning to work.
Participation arrangements and any special requests are specified in the confirmation issued by the Union.