Insurance Fraud Prevention Training Course

Duration 5 days 10 modules · 33 contact hours
Level Intermediate Certificate on completion
Who attends Claims Managers, Fraud Investigators and others
Fee from USD 1,100 KSh 95,000 for Kenyan organisations
Where 52 cities + online See dates by city
Next start 16 Nov 2026 Course code SD-FFC-041

Before you join: Participants should have practical familiarity with one or more insurance functions, such as claims, underwriting, policy administration, compliance, audit, investigations, payments or operations.

Dates & prices

Two start dates a month in every city, and live online on weekdays or weekends. Fees are per participant; classroom fees include tuition, materials, lunch and refreshments, and the certificate.

Suggest a date or city

Showing the next six months. Later dates, other cities and private deliveries for your team are available on request.

Course overview

Insurance fraud affects claim costs, pricing, customer trust and regulatory exposure. Fraud may arise at policy application, underwriting, claims, provider billing, premium collection and distribution. Teams must identify suspicious activity early without treating legitimate customers unfairly, disrupting valid claims or creating poorly evidenced allegations. Effective prevention requires more than red-flag lists: it depends on risk assessment, sound controls, disciplined investigations, reliable data and clear case decisions.

This course examines insurance fraud from initial risk identification through prevention, detection, investigation, response and recovery. Participants learn to classify fraud typologies, build fraud risk-and-control matrices, identify underwriting and claims indicators, use data-led detection methods and conduct structured investigations. The programme also addresses special investigation unit operating models, third-party controls, case governance, suspicious activity escalation and management reporting. Participants work with realistic cases involving motor accidents, property losses, medical billing, identity misuse, staged claims and intermediary collusion.

Teaching combines focused instructor briefings with case analysis, group discussion, fraud-scenario reviews, investigation simulations and control-design work. Participants use practical templates to assess a fraud scenario, prioritise referrals, document evidence, test controls and plan remedial action. Each participant leaves with a reusable insurance fraud prevention toolkit, including a fraud risk assessment model, claims triage checklist, investigation plan and 90-day improvement roadmap. Successful participants receive a certificate of completion.

The course is suited to professionals who manage or support insurance underwriting, claims, investigations, compliance, risk, audit, operations, data analysis or distribution oversight.

What you will be able to do

  • Classify insurance fraud typologies across underwriting, claims, distribution and payment processes
  • Conduct a fraud risk assessment using inherent risk, control effectiveness and residual risk
  • Design risk-and-control matrices for priority insurance fraud scenarios
  • Apply claims and underwriting red flags to make consistent referral decisions
  • Evaluate fraud detection rules and analytical results using precision, recall and alert volumes
  • Prepare an investigation plan, evidence log and fact-based investigation report
  • Test preventive and detective controls through walkthroughs, sampling and reperformance
  • Produce a 90-day fraud control remediation roadmap with owners and evidence requirements

Benefits of attending

For you

  • Make better-supported fraud referral and case-disposition decisions
  • Recognise staged claims, identity misuse and provider billing indicators
  • Document investigations to a standard suitable for management and legal review
  • Use detection metrics to challenge ineffective alert rules and thresholds
  • Build a credible fraud prevention improvement plan for a business area

For your organisation

  • Earlier identification of suspicious underwriting and claims activity
  • More consistent fraud referrals and investigation case files
  • Reduced payment leakage from weak approval and provider controls
  • Clearer management reporting on fraud exposure, savings and recoveries
  • Stronger evidence for audit findings, remediation and governance decisions

Course modules

10 modules over 5 days

Participants can classify major insurance fraud threats and explain their financial and operational consequences.

  • Insurance fraud typologies across underwriting, claims, distribution and premium collection
  • First-party, second-party and third-party fraud distinctions in case classification
  • Hard fraud versus soft fraud indicators and financial harm
  • Fraud Triangle drivers: pressure, opportunity and rationalisation in insurance cases
  • Organised fraud rings, collusion and identity misuse patterns
  • Victim, insurer and intermediary incentives shaping fraud exposure

Participants can assess fraud risk and assign clear governance responsibilities for treatment and escalation.

  • Board-approved fraud risk appetite statements and escalation thresholds
  • Three Lines Model accountabilities for business, risk, compliance and audit
  • Fraud risk assessment using inherent risk, controls and residual risk
  • Risk-and-control matrices linking scenarios, owners, evidence and testing
  • ISO 31000 treatment options applied to priority fraud scenarios
  • Key risk indicators calibrated to product, channel and claims stage

Participants can identify application fraud indicators and specify proportionate underwriting controls.

  • Know Your Customer checks for applicants, beneficial owners and payers
  • Application red flags: misrepresentation, non-disclosure, fronting and fictitious risks
  • Document authentication for identity, ownership, medical and valuation evidence
  • Sanctions, politically exposed persons and adverse-media screening boundaries
  • Straight-through processing controls and manual referral rules for exceptions
  • Agent due diligence, commission monitoring and delegated authority controls

Participants can assess claims indicators and route cases through an evidence-based triage process.

  • Claim triage models combining loss facts, claimant behaviour and policy history
  • Red-flag checklists for motor, property, health, life and liability claims
  • Timeline analysis testing policy inception, loss occurrence and notification chronology
  • Statement comparison techniques identifying inconsistencies, omissions and rehearsed narratives
  • Reserve changes and payment patterns signalling potential claim manipulation
  • Referral criteria separating routine verification from specialist investigation

Participants can interpret fraud analytics outputs and improve alert quality through structured testing.

  • Data quality tests for duplicates, missing values, outliers and conflicting identifiers
  • Link analysis connecting claimants, vehicles, providers, addresses and bank accounts
  • Benford's Law limitations when reviewing claim amounts and invoices
  • Rule-based detection scenarios, thresholds, alert volumes and false-positive control
  • Supervised model performance using precision, recall, lift and confusion matrices
  • Case-management queues prioritised by financial exposure, likelihood and evidential readiness

Participants can plan and document a proportionate insurance fraud investigation.

  • Investigation plans defining allegation, scope, hypotheses, sources and decision points
  • PEACE interviewing structure for cooperative, reluctant and potentially deceptive witnesses
  • Open-source intelligence collection with source recording and legal boundaries
  • Evidence logs preserving provenance, access history, relevance and chain of custody
  • Digital evidence handling for emails, photographs, telematics and social-media material
  • Investigation reports separating facts, analysis, findings, recommendations and uncertainty

Participants can design, test and improve controls that address identified fraud vulnerabilities.

  • Preventive, detective and corrective controls mapped against fraud scenarios
  • Segregation-of-duties design for claims approval, payments and supplier onboarding
  • Provider billing controls: pre-authorisation, coding edits and utilisation review
  • Payment controls using bank-account verification, maker-checker and exception reporting
  • Control testing through walkthroughs, sampling, reperformance and exception evaluation
  • Root-cause analysis using Five Whys and fishbone diagrams after confirmed fraud

Participants can make defensible fraud case decisions and manage escalation, recovery and customer-treatment risks.

  • Case disposition criteria: decline, voidance, recovery, referral or monitoring
  • Fair-treatment principles when suspending claims or challenging policyholder accounts
  • Legal counsel engagement, privilege boundaries and litigation-hold requirements
  • Suspicious activity reporting triggers and internal escalation protocols
  • Whistleblowing intake, confidentiality safeguards and retaliation-risk controls
  • Recovery options: subrogation, restitution, civil action and contractual set-off

Participants can define an effective fraud operating model for internal teams and external service providers.

  • Special investigation unit mandates, authority levels and independence safeguards
  • Fraud case-management workflow from intake through closure and lessons learned
  • Service-level agreements for referrals, evidence requests and management decisions
  • Investigator productivity measures: cycle time, conversion, savings and recoveries
  • Quality assurance reviews testing consistency, fairness and documented rationale
  • Third-party oversight for adjusters, repairers, medical providers and investigators

Participants can measure fraud programme performance and prepare a prioritised improvement plan.

  • Fraud loss measurement distinguishing prevented loss, avoided payment and recoveries
  • Balanced scorecards linking fraud controls, customer outcomes and operating costs
  • Control remediation plans with actions, owners, dates, evidence and dependencies
  • 90-day implementation roadmap prioritising high-risk products, channels and control gaps
  • Management reporting packs for trends, cases, decisions and residual risk
  • Personal application plan for first investigations, referrals and control reviews

Exercises and examples are adapted to each cohort's sectors and roles.

What you take back to work

  1. Insurance fraud risk assessment template
  2. Fraud risk-and-control matrix
  3. Claims fraud triage checklist
  4. Fraud investigation plan template
  5. Evidence log and case-report model
  6. 90-day fraud remediation roadmap

Who should attend

  • Claims Managers — need consistent triage, referral and case-decision processes
  • Fraud Investigators — require structured methods for evidence, interviews and reporting
  • Underwriting Managers — need controls against application fraud and material misrepresentation
  • Compliance and Financial Crime Officers — oversee fraud escalation, reporting and governance
  • Internal Auditors — assess fraud controls, case records and remediation evidence
  • Insurance Operations Managers — manage payment, provider and third-party fraud exposure

Skills and tools covered

Fraud risk assessmentClaims fraud detectionInvestigation planningEvidence managementControl testingFraud case governance

Tools and standards

Fraud Triangle, ISO 31000, PEACE interviewing model, Benford's Law

How the course runs

Training methodology

The instructor uses short technical briefings to introduce fraud typologies, controls, investigation methods and analytical measures. Participants analyse insurance cases, assess red flags, map fraud scenarios to controls and review evidence records. Group exercises examine claims triage, interview planning, case disposition and control failures. Simulations focus on making proportionate referral and investigation decisions from incomplete information. Throughout the course, participants adapt templates and planning tools to their own products, claims processes, third-party arrangements and reporting lines.

Requirements and prerequisites

Participants should have practical familiarity with one or more insurance functions, such as claims, underwriting, policy administration, compliance, audit, investigations, payments or operations. They should understand basic insurance terms including policyholder, premium, claim, reserve, indemnity, intermediary and third-party provider. Prior fraud investigation experience is useful but not required. The course does not require statistical modelling, programming, forensic accounting qualifications or legal training. Participants should bring examples of fraud risks or control issues they can discuss without disclosing confidential customer or case information.

A typical training day

08:30 – 10:30First session
10:30 – 10:45Refreshment break
10:45 – 12:30Second session
12:30 – 13:30Lunch and networking
13:30 – 15:00Third session
15:00 – 15:15Refreshment break
15:15 – 16:30Workshop and daily review

Live online deliveries follow the same structure in East Africa Time, with shorter screen blocks and longer breaks.

What the fee includes

  • Instruction by a practitioner facilitator
  • Full course workbook and materials
  • Exercise files, templates and case studies
  • Refreshments and lunch on classroom deliveries
  • Certificate of completion
  • Post-course application plan

Frequently asked questions

Participants should understand basic insurance operations or have experience in a related function such as claims, underwriting, compliance, audit or investigations. No prior fraud investigation qualification, programming skill or legal training is required.

Bring a laptop if possible, together with non-confidential examples of fraud concerns, control gaps or reporting challenges from your work. Course materials and working templates are provided.

The course is designed for insurance professionals with responsibility for claims, underwriting, fraud, compliance, risk, audit, operations or third-party oversight. It is also suitable for managers establishing or improving a fraud prevention programme.

This course focuses on insurance fraud risk, including application fraud, staged claims, provider billing, intermediary misconduct and claims payment controls. It addresses suspicious activity escalation where relevant, but it is not an anti-money laundering compliance programme.

Participants can use the templates to assess a fraud scenario, improve claims referral criteria, test a control or strengthen investigation documentation. The final implementation roadmap helps translate priorities into assigned actions and evidence requirements.

The five-day programme provides approximately 32.5 contact hours, normally from 08:30 to 16:30 each day. Time is divided between instructor input, case work, group exercises, simulations and application planning.

Questions about this course?

Ask about dates, fees, group bookings or running it for your team. Our training team replies by email.

Ask on WhatsApp info@skillsetdevelopment.com

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