Assess whether a provider should be suspended pending SIU (1fc510)

Situation

After three applications sharing one employer EIN and no payroll, Medicare upcoding CPT pairing table 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 Medicare upcoding CPT pairing table after three applications sharing one employer EIN and no payroll.

Hypotheses to test

• Three applications sharing one employer EIN and no payroll is noise around an already-controlled Payments Fraud process in a Medicare Advantage claims shop, given Medicare upcoding CPT pairing table.
• Three applications sharing one employer EIN and no payroll is the event in Medicare upcoding CPT pairing table that forces Remove access or reverse the item for bank BSA/AML case manager under Fraud Detection.
• Medicare upcoding CPT pairing table shows a one-file miss after three applications sharing one employer EIN and no payroll, not a Payments Fraud program failure.
• Medicare upcoding CPT pairing table cannot decide a provider should be yet after three applications sharing one employer EIN and no payroll; hold is the only Fraud Detection close a Medicare Advantage claims shop can defend.

Analysis required

• Trace funds, counterparties, and reversals in Medicare upcoding CPT pairing table through the window opened by three applications sharing one employer EIN and no payroll.
• Quantify loss if the hold is released before Medicare upcoding CPT pairing table 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 Medicare upcoding CPT pairing table against three applications sharing one employer EIN and no payroll 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 (Medicare upcoding CPT pairing table after three applications sharing one employer EIN and no payroll). The follow-on Payments Fraud action is what bank BSA/AML case manager does next: implement the option, assign an owner, and log the missing fact.