Assess whether a provider should be suspended pending SIU (ce3c51)

Situation

After a 400% utilization jump in 11 days, check-kiting multi-bank float map is what bank BSA/AML case manager can touch in a Medicare Advantage claims shop. Fraud Detection will live with Remove access or reverse the item versus Temporary compensating control on this Payments Fraud file.

Decision

Bank BSA/AML case manager in a Medicare Advantage claims shop must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using check-kiting multi-bank float map after a 400% utilization jump in 11 days.

Hypotheses to test

• Check-kiting multi-bank float map reads as Remove access or reverse the item once a 400% utilization jump in 11 days is lined up to the same Fraud Detection population.
• Check-kiting multi-bank float map is closer to Temporary compensating control after a 400% utilization jump in 11 days; Remove access or reverse the item would over-claim this Payments Fraud extract.
• Approve a documented exception is still live in check-kiting multi-bank float map for bank BSA/AML case manager in a Medicare Advantage claims shop.
• Check-kiting multi-bank float map is missing the fact bank BSA/AML case manager needs after a 400% utilization jump in 11 days; stop this Fraud Detection close.

Analysis required

• Trace funds, counterparties, and reversals in check-kiting multi-bank float map through the window opened by a 400% utilization jump in 11 days.
• Quantify loss if the hold is released before check-kiting multi-bank float map is complete.
• Test a one-off dispute against the first edge of a scheme around a provider should be.
• For this Fraud Detection Payments Fraud file, read check-kiting multi-bank float map against a 400% utilization jump in 11 days and write the one fact that would move a provider should be for bank BSA/AML case manager.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Payments Fraud packet (check-kiting multi-bank float map after a 400% utilization jump in 11 days). If check-kiting multi-bank float map cannot force a Fraud Detection label under Payments Fraud, stop. If check-kiting multi-bank float map after a 400% utilization jump in 11 days cannot support Remove access or reverse the item versus Temporary compensating control on this Fraud Detection Payments Fraud close, bank BSA/AML case manager must do not infer a control or scheme beyond the transaction and entitlement evidence.