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CS Professional · Internal and Forensic Audit · Special Points relating to Internal Audit in various Entities

An internal auditor of Sanjeevani Health Insurance Ltd wants to detect possible fraud in health claims by hospitals. Which data analytics test is most suitable?

The most suitable test is analytics that flags duplicate or near-identical claims, abnormal claim frequency by hospital, and early claims after policy inception. These are recognised fraud indicators in health claims. Sales totals, commission budgets and office layout do not reveal fraudulent claims.

  1. AIdentify duplicate or near-identical claims, unusually high claim frequency per hospital, and claims shortly after policy inceptionCorrect
  2. BTotal the number of policies sold each month
  3. CCompare agent commission against budget
  4. DReview the layout of the claims department

Explanation

Fraud indicators in health claims include duplicate billing, abnormal frequency from specific providers and early claims after inception. Analytics on these patterns flags suspicious cases for investigation. Sales totals, commission budgets and office layout do not point to claim fraud.

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