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Health Sector and Medical Scheme Claims Fraud Investigation

Fraud, waste and abuse drain a significant share of health funding across African medical schemes, insurers and public health systems. This course develops the skills to detect and investigate claims fraud by providers, members and syndicates. Delegates examine billing schemes, code manipulation, phantom services and the analytics and evidence needed to act.

What you will be able to do

  • Distinguish fraud, waste and abuse in health claims and billing.
  • Identify provider schemes such as upcoding, phantom billing and unbundling.
  • Detect member and syndicate fraud including card sharing and false claims.
  • Use claims analytics and pattern detection to prioritise investigations.
  • Gather clinical and documentary evidence while respecting patient privacy.
  • Recommend recovery, provider sanction and control improvements.

Course outline

  1. 01Fraud, Waste and Abuse in Health Funding
  2. 02Provider Billing and Coding Schemes
  3. 03Member and Syndicate Fraud
  4. 04Claims Analytics and Pattern Detection
  5. 05Clinical and Documentary Evidence
  6. 06Patient Privacy and Investigation Boundaries
  7. 07Recovery and Provider Sanctions
  8. 08Designing Anti Fraud Controls for Claims

Who should attend

This course is designed for medical scheme and health insurer staff, claims assessors, fraud investigators, clinical auditors and compliance officers in healthcare funding and provider organisations.

Dates, venues and fees

DatesVenueDaysFeeCalendar
17 to 19 Aug 2026Nairobi3US$1,500
24 to 26 Aug 2026Durban3R13,000
31 Aug to 2 Sep 2026Johannesburg3R13,000
14 to 16 Sep 2026Mauritius3US$1,500
21 to 23 Sep 2026Dubai3US$1,500
28 to 30 Sep 2026Lagos3US$1,500
5 to 7 Oct 2026Harare3US$1,500
12 to 14 Oct 2026Kampala3US$1,500
19 to 21 Oct 2026Dar es Salaam3US$1,500
26 to 28 Oct 2026Pretoria3R13,000
2 to 4 Nov 2026Cape Town3R13,000
16 to 18 Nov 2026Online3US$900
23 to 25 Nov 2026Mozambique3US$1,500
30 Nov to 2 Dec 2026Cairo3US$1,500
7 to 9 Dec 2026Accra3US$1,500
14 to 16 Dec 2026Lusaka3US$1,500
21 to 23 Dec 2026Kigali3US$1,500

Fees are per delegate. South African venues are priced in rand; other locations and online in US dollars. Fees exclude 15% VAT where applicable. Group bookings of three or more delegates from the same organisation qualify for a reduced rate; contact us for a quotation.

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