Fraud Detection and Prevention for the Insurance Industry

Course details

Why Attend

This course covers how to prevent fraud from happening, how to detect fraud, the tools to investigate fraud, and how to gather a case for prosecution. This course gives professionals working in the insurance industry the ability to protect their organization from internal fraudulent activity such as Agent/Broker premium diversion, re-insurance fraud and rented asset schemes. It also covers external fraud activities such as fake insurance companies, offshore/unlicensed internet companies, staged auto accidents, viatical and senior settlement fraud.

Course Methodology

This course uses a mixture of presentations, discussions, case studies, videos, role-plays and interactive exercises to transform participants’ knowledge into hands-on practice.

Course Objectives

• Define the role of ethics in insurance fraud prevention
• Distinguish the nature and types of insurance fraud
• Set up fraud prevention methods for the organization
• Identify and implement anti-fraud measures and manage fraud risks
• Investigate and form a legal case to prosecute suspected fraudsters

Target Audience

Target Competencies

• Auditing
• Preventing insurance fraud
• Detecting insurance fraud
• Implementing anti-fraud measures
• Investigating fraud

Course Outline

• Governance and ethics in insurance
  • Defining ethics
  • Ethics in the workplace
    • Conflicts of interest
    • Fraud
    • Racism
    • Other misconduct
  • Conducting ethics investigations
  • Skills and approaches of the ethics investigator
  • Moral hazard in insurance
  • Adverse selection

• Fighting fraud types
  • Core foundation: basic concepts of fraud, anti-fraud mind set
  • Life insurance fraud
  • Health insurance fraud
  • Auto insurance fraud
  • Property insurance fraud
  • Reporting insurance fraud
  • The role of the fraud investigator
  • Internal audit’s role in preventing fraud

• The broker’s perspective
  • Types of fraud
  • The broker’s role
  • Anti-fraud measures
    • In house anti-fraud units
    • Software alerts
    • Databases facilitating sharing of claims information (e.g., CUE, MIAFTR, MID, CIFAS)
    • Cognitive interviewing techniques
    • Lie detectors/voice stress analysis
    • Aerial photography and mapping
  • Managing broker fraud risks
  • Broker response to fraud

• Fraud Investigations
  • Tasks of the fraud investigator
  • Setting the standards
  • Reviewing controls
  • Searching for corroborating evidence
  • Spotting fraudulent claims
  • Theoretical and legal issues pertaining to fraud investigations
  • Multi-disciplinary approach to fraud investigations
  • General legal issues

• Criminal Investigations
  • Principles of criminal investigation
  • Collecting and systemizing of evidence
  • Forming statements
  • Interviewing and interrogation
  • Polygraph and statement analysis
  • Criminology/legal issues
  • Investigative techniques