Assess whether a provider should be suspended pending SIU (9e7d12)

Situation

After a mortgage occupancy affidavit contradicting utility records, mule-account payroll deposit pattern is what SIU investigator 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 Claims and Benefits Fraud file.

Decision

SIU investigator in a Medicare Advantage claims shop must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using mule-account payroll deposit pattern after a mortgage occupancy affidavit contradicting utility records.

Hypotheses to test

• The population in mule-account payroll deposit pattern is the one a mortgage occupancy affidavit contradicting utility records named, so Remove access or reverse the item follows for this Claims and Benefits Fraud file.
• The population in mule-account payroll deposit pattern is adjacent only to a mortgage occupancy affidavit contradicting utility records; Temporary compensating control is the honest Fraud Detection call.
• A Medicare Advantage claims shop already contained a mortgage occupancy affidavit contradicting utility records before mule-account payroll deposit pattern arrived; no new Claims and Benefits Fraud path.
• Provenance on mule-account payroll deposit pattern after a mortgage occupancy affidavit contradicting utility records is broken; do not pick Remove access or reverse the item or Temporary compensating control yet.

Analysis required

• Trace funds, counterparties, and reversals in mule-account payroll deposit pattern through the window opened by a mortgage occupancy affidavit contradicting utility records.
• Quantify loss if the hold is released before mule-account payroll deposit pattern is complete.
• Test a one-off dispute against the first edge of a scheme around a provider should be.
• For this Fraud Detection Claims and Benefits Fraud file, read mule-account payroll deposit pattern against a mortgage occupancy affidavit contradicting utility records and write the one fact that would move a provider should be for SIU investigator.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Claims and Benefits Fraud packet (mule-account payroll deposit pattern after a mortgage occupancy affidavit contradicting utility records). The follow-on Claims and Benefits Fraud action is what SIU investigator does next: implement the option, assign an owner, and log the missing fact.