Assess whether to refer to law enforcement or keep civil (f38158)

SITUATION A clinic billing the same modifier on 80% of visits put workers'-comp claimant attorney cluster in front of bank BSA/AML case manager in a Medicare Advantage claims shop. This Fraud Detection / Payments Fraud close is to refer to law from workers'-comp claimant attorney cluster, and the live options are To refer to law enforcement, Keep civil.

DECISION Bank BSA/AML case manager in a Medicare Advantage claims shop must choose To refer to law enforcement / Keep civil using workers'-comp claimant attorney cluster after a clinic billing the same modifier on 80% of visits.

HYPOTHESES TO TEST 1. A clinic billing the same modifier on 80% of visits is noise around an already-controlled Payments Fraud process in a Medicare Advantage claims shop, given workers'-comp claimant attorney cluster. 2. A clinic billing the same modifier on 80% of visits is the event in workers'-comp claimant attorney cluster that forces To refer to law enforcement for bank BSA/AML case manager under Fraud Detection. 3. Workers'-comp claimant attorney cluster shows a one-file miss after a clinic billing the same modifier on 80% of visits, not a Payments Fraud program failure. 4. Workers'-comp claimant attorney cluster cannot decide to refer to law yet after a clinic billing the same modifier on 80% of visits; hold is the only Fraud Detection close a Medicare Advantage claims shop can defend.

ANALYSIS REQUIRED 1. Test a one-off dispute against the first edge of a scheme around to refer to law. 2. Check mule or round-trip markers in workers'-comp claimant attorney cluster. 3. Map typology and hold authority bank BSA/AML case manager actually has in a Medicare Advantage claims shop. 4. For this Fraud Detection Payments Fraud file, read workers'-comp claimant attorney cluster against a clinic billing the same modifier on 80% of visits and write the one fact that would move to refer to law for bank BSA/AML case manager.

RECOMMENDATION Choose To refer to law enforcement / Keep civil on this Fraud Detection / Payments Fraud packet (workers'-comp claimant attorney cluster after a clinic billing the same modifier on 80% of visits). 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.

COMMAND RETURNS - Bottom-line Fraud Detection option on to refer to law, then the evidence in workers'-comp claimant attorney cluster, then the action for bank BSA/AML case manager - Hypothesis scorecard against workers'-comp claimant attorney cluster: supported / rejected / untestable - Named option among To refer to law enforcement, Keep civil and the fact that kills the others - Owner and next date for bank BSA/AML case manager in a Medicare Advantage claims shop