Whether a provider should be suspended pending SIU from Medicare upcoding CPT

Situation

A mule account receiving 14 unrelated payrolls in a week put Medicare upcoding CPT pairing table in front of payments-risk officer in a mortgage correspondent channel. This Fraud Detection / Credit and Identity Fraud close is a provider should be from Medicare upcoding CPT pairing table, and the live options are Remove access or reverse the item, Temporary compensating control, Approve a documented exception.

Decision

Payments-risk officer in a mortgage correspondent channel must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using Medicare upcoding CPT pairing table after a mule account receiving 14 unrelated payrolls in a week.

Hypotheses to test

• Medicare upcoding CPT pairing table reads as Remove access or reverse the item once a mule account receiving 14 unrelated payrolls in a week is lined up to the same Fraud Detection population.
• Medicare upcoding CPT pairing table is closer to Temporary compensating control after a mule account receiving 14 unrelated payrolls in a week; Remove access or reverse the item would over-claim this Credit and Identity Fraud extract.
• Approve a documented exception is still live in Medicare upcoding CPT pairing table for payments-risk officer in a mortgage correspondent channel.
• Medicare upcoding CPT pairing table is missing the fact payments-risk officer needs after a mule account receiving 14 unrelated payrolls in a week; stop this Fraud Detection close.

Analysis required

• Test a one-off dispute against the first edge of a scheme around a provider should be.
• Check mule or round-trip markers in Medicare upcoding CPT pairing table.
• Map typology and hold authority payments-risk officer actually has in a mortgage correspondent channel.
• For this Fraud Detection Credit and Identity Fraud file, read Medicare upcoding CPT pairing table against a mule account receiving 14 unrelated payrolls in a week and write the one fact that would move a provider should be for payments-risk officer.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Credit and Identity Fraud packet (Medicare upcoding CPT pairing table after a mule account receiving 14 unrelated payrolls in a week). Lead with the Fraud Detection option Medicare upcoding CPT pairing table can support after a mule account receiving 14 unrelated payrolls in a week, then the two facts that force it, then the Monday action for payments-risk officer in a mortgage correspondent channel.