Assess whether to refer to law enforcement or keep civil (675236)

SITUATION A clinic billing the same modifier on 80% of visits put check-kiting multi-bank float map in front of SIU investigator in a Medicare Advantage claims shop. This Fraud Detection / Claims and Benefits Fraud close is to refer to law from check-kiting multi-bank float map, and the live options are To refer to law enforcement, Keep civil.

DECISION SIU investigator in a Medicare Advantage claims shop must choose To refer to law enforcement / Keep civil using check-kiting multi-bank float map after a clinic billing the same modifier on 80% of visits.

HYPOTHESES TO TEST 1. SIU investigator can defend To refer to law enforcement from check-kiting multi-bank float map after a clinic billing the same modifier on 80% of visits in a Fraud Detection challenge. 2. SIU investigator cannot defend To refer to law enforcement from check-kiting multi-bank float map; Keep civil is what the extract actually supports after a clinic billing the same modifier on 80% of visits. 3. A clinic billing the same modifier on 80% of visits never reached the population in check-kiting multi-bank float map — reopen intake, do not close to refer to law. 4. Two facts in check-kiting multi-bank float map after a clinic billing the same modifier on 80% of visits conflict for SIU investigator; hold this Claims and Benefits Fraud file.

ANALYSIS REQUIRED 1. Quantify loss if the hold is released before check-kiting multi-bank float map is complete. 2. Test a one-off dispute against the first edge of a scheme around to refer to law. 3. Check mule or round-trip markers in check-kiting multi-bank float map. 4. For this Fraud Detection Claims and Benefits Fraud file, read check-kiting multi-bank float map against a clinic billing the same modifier on 80% of visits and write the one fact that would move to refer to law for SIU investigator.

RECOMMENDATION Choose To refer to law enforcement / Keep civil on this Fraud Detection / Claims and Benefits Fraud packet (check-kiting multi-bank float map after a clinic billing the same modifier on 80% of visits). 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.

COMMAND RETURNS - Bottom-line Fraud Detection option on to refer to law, then the evidence in check-kiting multi-bank float map, then the action for SIU investigator - Hypothesis scorecard against check-kiting multi-bank float map: supported / rejected / untestable - Claims and Benefits Fraud finding in check-kiting multi-bank float map that a second reviewer can re-perform - Missing page in check-kiting multi-bank float map after a clinic billing the same modifier on 80% of visits, if any