Should the Provider Be Suspended Pending SIU?

Situation

The desk packet is straw-buyer occupancy file after a mortgage occupancy affidavit contradicting utility records. Claims special-investigation lead in a Medicare Advantage claims shop has to name Remove access or reverse the item or Temporary compensating control for this Fraud Detection Credit and Identity Fraud file.

Decision

Claims special-investigation lead in a Medicare Advantage claims shop must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using straw-buyer occupancy file after a mortgage occupancy affidavit contradicting utility records.

Hypotheses to test

• Authorize Remove access or reverse the item now; straw-buyer occupancy file already has the discriminator after a mortgage occupancy affidavit contradicting utility records.
• Keep Temporary compensating control in force until straw-buyer occupancy file is completed after a mortgage occupancy affidavit contradicting utility records for claims special-investigation lead.
• Treat straw-buyer occupancy file as Approve a documented exception because both readings appear after a mortgage occupancy affidavit contradicting utility records.
• Refuse a Fraud Detection close: claims special-investigation lead does not have the page a provider should be turns on in straw-buyer occupancy file.

Analysis required

• Trace funds, counterparties, and reversals in straw-buyer occupancy file through the window opened by a mortgage occupancy affidavit contradicting utility records.
• Quantify loss if the hold is released before straw-buyer occupancy file is complete.
• Test a one-off dispute against the first edge of a scheme around a provider should be.
• For this Fraud Detection Credit and Identity Fraud file, read straw-buyer occupancy file against a mortgage occupancy affidavit contradicting utility records and write the one fact that would move a provider should be 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 / Credit and Identity Fraud packet (straw-buyer occupancy file after a mortgage occupancy affidavit contradicting utility records). If straw-buyer occupancy file cannot force a Fraud Detection label under Credit and Identity Fraud, stop. Do not invent pages a Medicare Advantage claims shop does not have.