Health Insurance Risk and Claims Management Training Course

Health Insurance Risk and Claims Management Training Course

Introduction

The modern healthcare industry faces unprecedented challenges driven by escalating costs, complex regulatory landscapes, and the rapid adoption of new technologies. Effective Health Insurance Risk and Claims Management is not just an administrative function; it is a critical strategic imperative for the sustainability and profitability of insurance carriers, Third-Party Administrators (TPAs), and self-insured organizations. Health Insurance Risk and Claims Management Training Course is designed to empower professionals with data-driven decision-making skills, focusing on financial solvency, fraud detection, and enhancing the customer experience (CX). Success in this field demands a proactive approach to risk stratification and a deep understanding of the claims lifecycle to minimize leakage and ensure regulatory compliance.

This course delves into cutting-edge strategies, moving beyond traditional claims processing to embrace modern Enterprise Risk Management (ERM) frameworks tailored for health insurance. Participants will master techniques for leveraging predictive analytics and AI in claims to identify high-risk areas, optimize provider network management, and combat sophisticated healthcare fraud, waste, and abuse (FWA). By integrating robust risk mitigation with efficient claims adjudication, organizations can significantly improve their loss ratio, maintain a competitive edge, and ultimately deliver on their core promise of timely and accurate coverage. The emphasis is on practical application, using real-world case studies to translate theoretical concepts into actionable, high-impact business strategies.

Course Duration

5 days  

Course Objectives

1. Master the principles of Health Insurance Risk Stratification and profiling.
2. Implement an effective Enterprise Risk Management (ERM) framework for health payers.
3. Utilize Predictive Modeling for claims forecasting and reserve setting.
4. Develop advanced strategies for Healthcare Fraud, Waste, and Abuse (FWA) Detection.
5. Optimize the Claims Adjudication Process using Automation and AI.
6. Ensure full adherence to HIPAA and evolving Regulatory Compliance standards.
7. Analyze and reduce Claims Leakage and administrative costs.
8. Design and manage profitable Provider Networks and contracting models (Value-Based Care).
9. Improve the Member Experience (CX) throughout the claims journey.
10. Integrate Telehealth and Digital Health technologies into risk assessment.
11. Conduct effective Claims Auditing and internal control assessments.
12. Quantify and manage financial risks, including Underwriting Risk and Reinsurance.
13. Apply Data Analytics and Business Intelligence for continuous process improvement.

Target Audience

1. Claims Managers/Adjusters (Health Insurance Carriers and TPAs)
2. Risk Management Professionals (Insurers and Self-Funded Employers)
3. Underwriters (Specializing in Group and Individual Health)
4. Compliance and Legal Officers (Healthcare and Insurance)
5. Financial Auditors and Internal Controls Specialists
6. Data Scientists/Analysts (Focusing on Insurance/Health Data)
7. Provider Relations and Contracting Staff
8. Healthcare Consultants and Operations Executives

Course Modules

Module 1: Foundations of Health Insurance Risk

• Risk Identification
• Risk Quantification
• Risk Transfer Mechanisms.
• Underwriting Principle.
• Understanding the Law of Large Numbers and adverse selection.
• Case Study: Analyzing a health carrier's sudden spike in adverse selection following a product launch and developing revised underwriting guidelines.

Module 2: Enterprise Risk Management (ERM) Framework

• Establishing the risk appetite, culture, and reporting structure.
• Defining metrics for claims volume, payment accuracy, and fraud.
• Techniques for financial hedging and operational controls.
• Business Continuity Planning
• Solvency and Capital Adequacy
• Case Study: Designing a Cyber Risk management plan for a TPA following a major data breach involving member claims data.

Module 3: Advanced Claims Adjudication and Automation

• End-to-end processing from intake to final payment/denial.
• Preventing erroneous payments, duplicate claims, and overbilling.
• Implementing bots for repetitive claims tasks.
• Using algorithms for automated claim review and pattern matching.
• Setting and monitoring standards for turnaround time and accuracy.
• Case Study: Implementing an RPA system to automate 60% of low-complexity, clean claims, analyzing the resulting reduction in processing time and cost.

Module 4: Fraud, Waste, and Abuse (FWA) Detection and Prevention

• Identifying schemes
• Predictive Fraud Analytics.
• Special Investigation Unit (SIU) Role.
• Strategies for recouping funds lost to FWA and errors.
• Navigating legal and regulatory obligations for suspected fraud.
• Case Study: Using Network Analysis to uncover a collusion ring between a physician and a pharmacy, resulting in millions in fraudulent claims.

Module 5: Regulatory Compliance and Governance

• Detailed rules on privacy, security, and transaction standards.
• Impact on essential health benefits and claims practices.
• Preparing for and responding to regulatory audits.
• Establishing a fair and compliant process for member disputes.
• Ensuring claims decisions are defensible and transparent.
• Case Study: Reviewing and revising a claims denial letter template to ensure it meets all mandated Grievance and Appeals regulatory requirements.

Module 6: Data Analytics and Business Intelligence in Claims

• Monitoring loss ratio, expense ratio, and claim settlement cycle time.
• Creating dashboards for executive reporting and operational oversight.
• Forecasting future claims liability and reserve adequacy.
• Using data to pinpoint sources of payment errors and high-cost claims.
• Comparing operational efficiency and performance against industry standards.
• Case Study: Analyzing claims data to identify the top 5 drivers of medical loss ratio (MLR) variance and developing targeted cost-containment programs.

Module 7: Provider Network and Value-Based Care Risk

• Fee-for-Service, Capitation and Value-Based Arrangements.
• Managing the risk associated with network quality and compliance.
• Implementing pre-authorization and concurrent review to control costs.
• Stratifying members to manage chronic conditions and complex care.
• Designing payment models that reward quality and cost efficiency.
• Case Study: Assessing the financial and quality risk of transitioning a major hospital group from a FFS model to a bundled payment arrangement.

Module 8: Member Experience and Digital Transformation

• Designing processes that prioritize transparency and speed.
• Implementing mobile and portal-based claims filing.
• Providing 24/7 claims status and information.
• Managing the claims and risk implications of virtual care delivery.
• Handling social media and public fallout from claims issues.
• Case Study: Developing a digital communication strategy to proactively update members on claims status, aiming to reduce inquiry calls by 40% and boost Net Promoter Score (NPS).

Training Methodology

This course employs a participatory and hands-on approach to ensure practical learning, including:

• Interactive lectures and presentations.
• Group discussions and brainstorming sessions.
• Hands-on exercises using real-world datasets.
• Role-playing and scenario-based simulations.
• Analysis of case studies to bridge theory and practice.
• Peer-to-peer learning and networking.
• Expert-led Q&A sessions.
• Continuous feedback and personalized guidance.

Register as a group from 3 participants for a Discount

Send us an email: info@datastatresearch.org or call +254724527104 

Certification

Upon successful completion of this training, participants will be issued with a globally- recognized certificate.

Tailor-Made Course

 We also offer tailor-made courses based on your needs.

Key Notes

a. The participant must be conversant with English.

b. Upon completion of training the participant will be issued with an Authorized Training Certificate

c. Course duration is flexible and the contents can be modified to fit any number of days.

d. The course fee includes facilitation training materials, 2 coffee breaks, buffet lunch and A Certificate upon successful completion of Training.

e. One-year post-training support Consultation and Coaching provided after the course.

f. Payment should be done at least a week before commence of the training, to DATASTAT CONSULTANCY LTD account, as indicated in the invoice so as to enable us prepare better for you.