Assess whether the model score is a false positive from a life event (0f0775)

Situation

Claims and Benefits Fraud work in a Medicare Advantage claims shop now turns on the model score is because a mule account receiving 14 unrelated payrolls in a week put straw-buyer occupancy file in play. Claims and Benefits Fraud work in a Medicare Advantage claims shop now turns on the model score is because a mule account receiving 14 unrelated payrolls in a week put straw-buyer occupancy file in play; SIU investigator should say what straw-buyer occupancy file proves for Fraud Detection.

Decision

SIU investigator 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 mule account receiving 14 unrelated payrolls in a week.

Hypotheses to test

• Straw-buyer occupancy file reads as Remove access or reverse the item once a mule account receiving 14 unrelated payrolls in a week is lined up to the same Fraud Detection population.
• Straw-buyer occupancy file is closer to Temporary compensating control after a mule account receiving 14 unrelated payrolls in a week; Remove access or reverse the item would over-claim this Claims and Benefits Fraud extract.
• Approve a documented exception is still live in straw-buyer occupancy file for SIU investigator in a Medicare Advantage claims shop.
• Straw-buyer occupancy file is missing the fact SIU investigator needs after a mule account receiving 14 unrelated payrolls in a week; stop this Fraud Detection close.

Analysis required

• 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 the model score is.
• Check mule or round-trip markers in straw-buyer occupancy file.
• For this Fraud Detection Claims and Benefits Fraud file, read straw-buyer occupancy file against a mule account receiving 14 unrelated payrolls in a week and write the one fact that would move the model score is for SIU investigator.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Claims and Benefits Fraud packet (straw-buyer occupancy file after a mule account receiving 14 unrelated payrolls in a week). 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.