Assess whether a trial site should be referred (1cedf5)

Situation

IG improper-payments investigator in a Medicare contractor SIU pack has one working extract — Medicare billing-pattern outlier table — after a provider with a sudden modifier-25 spike. If Medicare billing-pattern outlier table cannot support a trial site should be referred, the honest US Federal output is hold.

Decision

IG improper-payments investigator in a Medicare contractor SIU pack must choose Pursue / Pursue with conditions / Partner / No-bid using Medicare billing-pattern outlier table after a provider with a sudden modifier-25 spike.

Hypotheses to test

• Medicare billing-pattern outlier table reads as Pursue once a provider with a sudden modifier-25 spike is lined up to the same US Federal population.
• Medicare billing-pattern outlier table is closer to Pursue with conditions after a provider with a sudden modifier-25 spike; Pursue would over-claim this Healthcare Compliance Fraud extract.
• Partner is still live in Medicare billing-pattern outlier table for IG improper-payments investigator in a Medicare contractor SIU pack.
• Medicare billing-pattern outlier table is missing the fact IG improper-payments investigator needs after a provider with a sudden modifier-25 spike; stop this US Federal close.

Analysis required

• Normalize pricing and CPARS/QASP evidence that actually supports a trial site should be referred.
• Compare PTW and compliance gates in Medicare billing-pattern outlier table to a pursue / partner / no-bid split.
• Test OCI and SAM.gov status before a Medicare contractor SIU pack commits.
• For this US Federal Healthcare Compliance Fraud file, read Medicare billing-pattern outlier table against a provider with a sudden modifier-25 spike and write the one fact that would move a trial site should be referred for IG improper-payments investigator.

Recommendation

Choose Pursue / Pursue with conditions / Partner / No-bid on this US Federal / Healthcare Compliance Fraud packet (Medicare billing-pattern outlier table after a provider with a sudden modifier-25 spike). The follow-on Healthcare Compliance Fraud action is what IG improper-payments investigator does next: implement the option, assign an owner, and log the missing fact.