Assess whether an eligibility case is error, fraud, or both (9405de)

Situation

An eligibility case is sits with Medicaid eligibility integrity analyst because a MAGI mismatch that could be a household-size coding error hit a Medicaid agency with a surge in MAGI mismatches. Evidence is recoupment aging versus collectability; write the Public Benefits Compliance and Integrity Operations option that extract can carry.

Decision

Medicaid eligibility integrity analyst in a Medicaid agency with a surge in MAGI mismatches must choose An eligibility case is error, fraud, / Both using recoupment aging versus collectability after a MAGI mismatch that could be a household-size coding error.

Hypotheses to test

• Recoupment aging versus collectability reads as An eligibility case is error, fraud, once a MAGI mismatch that could be a household-size coding error is lined up to the same Public Benefits population.
• Recoupment aging versus collectability is closer to Both after a MAGI mismatch that could be a household-size coding error; An eligibility case is error, fraud, would over-claim this Compliance and Integrity Operations extract.
• A dual reading is still live in recoupment aging versus collectability for Medicaid eligibility integrity analyst in a Medicaid agency with a surge in MAGI mismatches.
• Recoupment aging versus collectability is missing the fact Medicaid eligibility integrity analyst needs after a MAGI mismatch that could be a household-size coding error; stop this Public Benefits close.

Analysis required

• Match household facts in recoupment aging versus collectability to the rule that pays the benefit.
• Trace the notice and appeal path Medicaid eligibility integrity analyst must preserve.
• Test eligibility, recoupment, and improper-payment facts in recoupment aging versus collectability after a MAGI mismatch that could be a household-size coding error.
• For this Public Benefits Compliance and Integrity Operations file, read recoupment aging versus collectability against a MAGI mismatch that could be a household-size coding error and write the one fact that would move an eligibility case is for Medicaid eligibility integrity analyst.

Recommendation

Choose An eligibility case is error, fraud, / Both on this Public Benefits / Compliance and Integrity Operations packet (recoupment aging versus collectability after a MAGI mismatch that could be a household-size coding error). The follow-on Compliance and Integrity Operations action is what Medicaid eligibility integrity analyst does next: implement the option, assign an owner, and log the missing fact.