Health-Insurance Procedures and Systems

Most health insurance problems are process problems. Benefits are described one way in the policy and configured another way in the claims system. Pre-authorisation rules are applied inconsistently. Clinical documentation does not support the codes submitted, so claims are rejected or reduced. Payers struggle to separate fraud, waste and abuse from honest error, and providers see rising denial rates without knowing the root cause. Each party blames the other, and the member is caught in the middle.

This programme follows the life of a health insurance contract from product design to paid claim. It moves through five stages: how health insurance works and how products are built, how members and providers are brought into the scheme, how eligibility and pre-authorisation are managed, how claims are coded, adjudicated and paid, and how the whole cycle is monitored for leakage, fraud and service quality.

Built on recognised practice. The programme references WHO guidance on health financing and the WHO International Classification of Diseases (ICD-10 and ICD-11), common procedure coding and casemix concepts such as diagnosis-related groups (DRGs), and electronic claims exchange and data standards such as HL7 FHIR. Participants also review how regional regulators set mandatory cover, provider accreditation and electronic claims requirements, and how these shape daily procedures.

Decisions this programme improves. Whether a benefit design can be administered as written; which services need pre-authorisation and which do not; how to set provider network and tariff arrangements; when to reject, reduce or query a claim; how to investigate suspected fraud fairly; and which indicators managers need to see to control cost and service.

How it is delivered. Twenty hours across five sessions, built around one running case: a medical scheme for a large employer, followed from policy set-up through pre-authorisation requests, a batch of claims with coding and documentation issues, and a payer and provider dispute. Participants adjudicate sample claims and design a monthly claims dashboard.

In-house option. For organisations, the programme can be tailored to your own products, policy wordings, provider contracts, claims system and regulatory environment, and delivered for payer, provider revenue cycle and TPA teams together so that everyone works from the same rules.

Who Should Attend

Insurers and TPAs: claims managers, medical reviewers, pre-authorisation staff, underwriters and provider relations staff

Healthcare providers: revenue cycle managers, insurance and billing officers, coding and medical records staff

Government schemes and regulators: staff in health insurance bodies, ministries and public health funds who oversee schemes and claims

Employers: HR and benefits managers who manage group medical schemes

Clinical staff: physicians and nurses moving into medical review or insurance liaison roles

Objectives

Explain how health insurance products, risk pooling and premium setting work in practice

Translate a benefit schedule into clear administration rules, limits, exclusions and co-payments

Manage member enrolment, eligibility verification and card issue with appropriate controls

Apply pre-authorisation and utilisation review procedures consistently and within service standards

Check that claims are supported by clinical documentation and correctly coded using ICD and procedure codes

Adjudicate claims against policy terms, provider contracts and tariffs, and document the reasons for decisions

Identify the main causes of claim rejections and design fixes on both payer and provider sides

Recognise indicators of fraud, waste and abuse and follow a fair investigation process

Handle appeals, complaints and payer and provider disputes in a structured way

Build a set of indicators that tracks cost, turnaround time, rejection rates and member experience

Course Outline

How Health Insurance Works: Products, Risk and the Regulatory Frame

Principles of health insurance: risk pooling, adverse selection and moral hazard
Public, mandatory employer and private schemes: roles of regulators, insurers, TPAs and providers
Product design: benefit schedules, limits, exclusions, co-payments and deductibles
Premium setting basics: claims experience, utilisation trends and medical inflation
Policy wording that can be administered: avoiding ambiguity between sales, underwriting and claims
Regulatory requirements for mandatory cover, data and electronic claims in the region

Members and Providers: Enrolment, Networks and Contracts

Member enrolment, eligibility data and card issue
Underwriting at group and individual level, and pre-existing condition rules
Provider network design: tiers, access and quality criteria
Provider contracting: fee-for-service, packages, capitation and DRG-based payment
Tariff management and price list control in the claims system
Service level agreements between payers, TPAs and providers

Pre-Authorisation and Utilisation Management

Which services need prior approval and why
Eligibility checks, medical necessity and clinical guidelines
Turnaround standards for routine and emergency requests
Case management for high-cost and chronic conditions
Communicating decisions to providers and members clearly and fairly
Measuring the effect of utilisation management on cost and access

Claims: Coding, Adjudication and Payment

The claims cycle from submission to payment and reconciliation
Clinical documentation and coding with ICD-10 and ICD-11, procedure codes and DRG grouping
Electronic claims submission, data standards and automated validation edits
Adjudication rules: coverage, limits, tariffs, duplicates and bundling
Common rejection reasons and how providers and payers can reduce them
Remittance, reconciliation and handling of resubmissions and appeals

Controlling Leakage and Improving the System

Fraud, waste and abuse: typical patterns on provider, member and internal sides
Detection using data analytics and rules, and the limits of automated flags
Fair investigation, recovery and escalation procedures
Claims audit: sampling, findings and corrective action
Indicators and dashboards: loss ratio, cost per member, turnaround time and rejection rates
Digital claims platforms and the practical use of analytics and AI in claims review
Action plan: strengthening procedures in your organisation

Competencies

Health insurance product and benefit design

Member enrolment and eligibility control

Provider network and contract management

Pre-authorisation and utilisation management

Clinical coding and claims documentation

Claims adjudication and payment reconciliation

Denial management and dispute resolution

Fraud, waste and abuse detection

Claims performance indicators and reporting

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