Assess whether occupancy was misrepresented at origination (e60a96)

Situation

Medicare upcoding CPT pairing table arrived with a check deposited in two banks the same afternoon for claims special-investigation lead. That is a Fraud Detection Payments Fraud decision on occupancy was misrepresented at in a P&C carrier's auto-body network.

Decision

Claims special-investigation lead in a P&C carrier's auto-body network must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using Medicare upcoding CPT pairing table after a check deposited in two banks the same afternoon.

Hypotheses to test

• The population in Medicare upcoding CPT pairing table is the one a check deposited in two banks the same afternoon named, so Remove access or reverse the item follows for this Payments Fraud file.
• The population in Medicare upcoding CPT pairing table is adjacent only to a check deposited in two banks the same afternoon; Temporary compensating control is the honest Fraud Detection call.
• A P&C carrier's auto-body network already contained a check deposited in two banks the same afternoon before Medicare upcoding CPT pairing table arrived; no new Payments Fraud path.
• Provenance on Medicare upcoding CPT pairing table after a check deposited in two banks the same afternoon is broken; do not pick Remove access or reverse the item or Temporary compensating control yet.

Analysis required

• Map typology and hold authority claims special-investigation lead actually has in a P&C carrier's auto-body network.
• Trace funds, counterparties, and reversals in Medicare upcoding CPT pairing table through the window opened by a check deposited in two banks the same afternoon.
• Quantify loss if the hold is released before Medicare upcoding CPT pairing table is complete.
• For this Fraud Detection Payments Fraud file, read Medicare upcoding CPT pairing table against a check deposited in two banks the same afternoon and write the one fact that would move occupancy was misrepresented at for claims special-investigation lead.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Payments Fraud packet (Medicare upcoding CPT pairing table after a check deposited in two banks the same afternoon). The follow-on Payments Fraud action is what claims special-investigation lead does next: implement the option, assign an owner, and log the missing fact.