Healthcare Insurance Management Training Course

Participants can assess benefit design choices and their effects on coverage and cost.

• Benefit schedules defining covered services, limits, exclusions and waiting periods
• Cost-sharing structures using deductibles, copayments, coinsurance and annual maximums
• Medical necessity criteria guiding coverage decisions and utilisation review
• Product segmentation for individual, group, corporate and public schemes
• Policy wording controls reducing ambiguity in benefit interpretation disputes
• Benefit change impact assessed through utilisation, affordability and member access

Participants can establish eligibility and enrolment controls that protect coverage accuracy.

• Eligibility rules for employees, dependants, retirees and continuation coverage
• Enrolment workflows validating identity, effective dates and benefit selections
• Premium contribution records reconciled against member eligibility files monthly
• Life-event changes processed through documented evidence and approval controls
• Member identification methods preventing duplicate records and eligibility errors
• Termination controls stopping coverage and claims exposure at correct dates

Participants can evaluate underwriting information and identify portfolio risk drivers.

• Underwriting data requirements for groups, populations and benefit plan designs
• Demographic risk factors including age, family composition and geographic location
• Experience rating methods using historical claims, exposure and trend adjustments
• Community rating principles and regulatory limits on risk selection
• Pre-existing condition rules assessed against applicable market requirements
• Underwriting referrals triggered by adverse experience and incomplete disclosures

Participants can interpret core pricing and financial measures used in health insurance management.

• Premium rating components covering expected claims, expenses, margin and taxes
• Medical trend assumptions separating price inflation, utilisation and benefit mix
• Loss ratio calculations comparing incurred claims with earned premium
• IBNR reserve concepts for reported delays and incomplete claims information
• Administrative expense ratio monitored alongside medical cost performance
• Pricing adequacy reviewed using renewal results, claims development and retention

Participants can map the claims process and apply core adjudication controls.

• Claims intake checks for member eligibility, provider identity and required documentation
• Adjudication rules applying benefits, exclusions, limits and cost-sharing provisions
• Clean claim definitions supporting turnaround-time measurement and service commitments
• Payment authorisation matrices separating assessment, approval and release responsibilities
• Denial reason codes structured for consistent communication and trend analysis
• Claims turnaround metrics segmented by claim type, channel and complexity

Participants can use coding and payment concepts to identify claims accuracy risks.

• ICD-10 diagnosis codes supporting clinical classification and utilisation analysis
• CPT and procedure coding principles used in outpatient claims assessment
• DRG payment concepts applied to inpatient episode reimbursement reviews
• Coding edits detecting incompatible diagnoses, procedures and service settings
• Bundling rules preventing separate payment for included clinical services
• Clinical documentation requirements supporting coding accuracy and payment decisions

Participants can design payment-integrity controls for common claims leakage risks.

• Duplicate claim detection using member, provider, date and amount matching
• Outlier analysis identifying unusual billing volumes, costs and service patterns
• Prepayment edits stopping invalid claims before funds are released
• Postpayment recovery workflows documenting findings, notifications and repayment actions
• Coordination of benefits rules allocating liability between multiple insurers
• Control testing samples measuring adjudication accuracy and payment exceptions

Participants can distinguish fraud, waste and abuse and manage investigation referrals.

• Fraud, waste and abuse definitions distinguished through intent and evidence
• Red-flag indicators for providers, members, pharmacies and intermediaries
• Case triage scoring based on financial exposure, evidence and urgency
• Investigation files preserving claim records, communications and decision rationale
• Provider audit approaches including desk reviews, interviews and record sampling
• Referral protocols linking claims teams, legal counsel and enforcement authorities

Participants can apply utilisation management methods to support appropriate care and cost control.

• Prior authorisation criteria for high-cost procedures, medicines and admissions
• Concurrent review processes monitoring length of stay and discharge readiness
• Retrospective review methods assessing medical necessity after treatment completion
• Case management interventions for complex, chronic and high-cost members
• Utilisation rates compared by provider, diagnosis, benefit and member segment
• Escalation pathways balancing clinical judgement, policy terms and member rights

Participants can assess pharmacy benefit controls and medication-cost management options.

• Formulary design classifying preferred, restricted and excluded medicines
• Generic substitution rules reducing costs while maintaining therapeutic equivalence
• Prior authorisation controls for specialty medicines and high-cost therapies
• Pharmacy network arrangements affecting dispensing cost and member access
• Medication adherence indicators identifying refill gaps and chronic-care risks
• Pharmacy claims analytics detecting unusual quantities, frequency and prescriber patterns

Participants can plan provider networks that balance access, quality and affordability.

• Network adequacy measures covering geography, capacity, specialties and appointment access
• Provider segmentation based on volume, cost, quality and strategic importance
• Open and closed network models compared for member choice
• Referral pathways directing members toward appropriate providers and care settings
• Provider concentration risk measured through spend, dependency and replacement options
• Network expansion cases assessed using utilisation demand and access gaps

Participants can evaluate provider contract terms and reimbursement mechanisms.

• Fee schedules specifying reimbursable services, rates and billing requirements
• Capitation arrangements allocating per-member payment and defined service responsibility
• Case-rate contracts establishing payment for defined treatment episodes
• Contract clauses addressing authorisation, coding, audits and dispute resolution
• Quality incentives linked to agreed clinical, access and service measures
• Provider negotiation preparation using volume, cost and performance evidence

Participants can monitor quality and service measures relevant to health insurance performance.

• Quality indicators covering readmissions, complications, preventive care and outcomes
• Member experience measures tracking access, communication and complaint resolution
• Grievance procedures documenting appeals, clinical reviews and final determinations
• Service-level agreements defining response times, ownership and escalation requirements
• Root-cause analysis applied to recurring complaints and service breakdowns
• Quality governance committees reviewing trends, actions and accountability records

Participants can specify useful analyses from health insurance operational and claims data.

• Claims data fields linking members, providers, diagnoses, procedures and payments
• Data quality checks for completeness, validity, duplicates and timeliness
• Cohort analysis comparing utilisation patterns across enrolment periods and populations
• Frequency and severity analysis separating claim incidence from average cost
• Dashboard design combining financial, operational, provider and member measures
• Data governance roles assigning ownership, access approval and retention requirements

Participants can diagnose health insurance performance using financial and operational indicators.

• Medical loss ratio tracked against budget, pricing assumptions and prior periods
• Claims development analysis explaining reserve changes and emerging cost patterns
• Expense allocation methods separating acquisition, administration and claims costs
• Variance analysis linking adverse results to volume, price and utilisation
• Management reporting packs connecting financial results with operational drivers
• Corrective action plans assigning owners, milestones, measures and governance reviews

Participants can assess reinsurance arrangements and catastrophic medical cost exposure.

• Specific stop-loss cover protecting insurers against individual high-cost claims
• Aggregate stop-loss structures limiting total portfolio claims exposure
• Attachment points and limits aligned with retained risk appetite
• Reinsurance bordereaux reporting ceded claims, recoveries and outstanding balances
• Catastrophic event scenarios estimating surge claims and provider capacity pressure
• Recovery controls reconciling reinsurer notifications, documentation and settlements

Participants can identify key governance requirements affecting healthcare insurance operations.

• Insurance conduct requirements covering disclosures, fairness and complaint handling
• Health data privacy principles governing collection, use and disclosure
• Consent management records supporting lawful processing of sensitive health information
• Anti-money laundering controls relevant to premium refunds and intermediaries
• Sanctions screening requirements for payments, providers and third-party relationships
• Compliance monitoring plans testing controls, incidents and remediation progress

Participants can identify operational risks and prepare continuity controls for health insurance services.

• Risk registers documenting events, causes, controls, owners and residual ratings
• Claims system outage scenarios protecting payment continuity and member communication
• Third-party risk assessments for administrators, call centres and technology vendors
• Business continuity plans prioritising critical claims and authorisation processes
• Incident reporting thresholds distinguishing operational failures, breaches and suspected fraud
• Control self-assessments testing design effectiveness and evidence availability

Participants can build, review and present a complete healthcare insurance management plan for a defined portfolio.

• Portfolio diagnostic integrating claims, utilisation, provider, service and financial evidence
• Benefit and underwriting recommendations aligned with risk and affordability findings
• Claims-control model specifying edits, exceptions, reviews and recovery actions
• Provider scorecard defining cost, quality, access and contract measures
• Implementation roadmap sequencing actions, accountable owners, milestones and dependencies
• Management presentation defending recommendations, risks, metrics and governance arrangements