Format: On demand
Duration: 200 Mins
Instructors: Coral MED
Learning Credits: 0.2 CEU
*This course was updated on Jan 01, 1970.
This unit provides a comprehensive overview of techniques and tools used to detect healthcare fraud. Learners explore both traditional and technology-driven methods of uncovering fraudulent activities in billing, claims, and healthcare documentation. The course introduces data analysis, pattern recognition, risk indicators, and audit sampling as core components of an effective detection system. Learners examine real-world case studies where advanced analytics, internal controls, and whistleblower reports have exposed fraud. Emphasis is placed on combining quantitative (data-driven) and qualitative (behavioral and compliance-based) approaches to create robust fraud detection systems that support transparency and integrity in healthcare operations.
Define key fraud detection techniques used in healthcare organizations. Explain the foundational role of data analysis in proactively identifying fraudulent activities. Analyze the pivotal role of internal audits in detecting and mitigating fraudulent activities. Analyze the application of advanced technologies, such as machine learning and artificial intelligence, in modern healthcare fraud detection. Apply key fraud detection techniques and auditing methodologies to analyze simulated healthcare scenarios and identify potential fraudulent activities. Evaluate the effectiveness of different fraud detection tools and technologies by assessing their outcomes, efficiency, and limitations. Design a protocol for investigating a potential fraud case identified through detection tools.
By the end of this unit, learners will be able to: Recognize patterns and data anomalies that indicate fraudulent behavior. Utilize basic data analytics tools to identify potential fraud cases. Integrate fraud detection methods into organizational compliance frameworks. Communicate findings to compliance and legal teams using clear documentation. Contribute to proactive and technology-driven fraud prevention strategies in healthcare.
Completion of first session, Introduction to Healthcare Fraud or prior exposure to healthcare compliance, auditing, or data management concepts.
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Compliance officers and auditors monitoring financial integrity and billing accuracy. Healthcare fraud investigators seeking to enhance detection capabilities. Data analysts and IT professionals working in fraud analytics or risk management. Healthcare administrators responsible for compliance oversight. Students and emerging professionals pursuing healthcare auditing, forensic accounting, or regulatory compliance careers.