Assess whether occupancy was misrepresented at origination (286b8e)

Situation

Payments Fraud work in a workers'-comp insurer after a surge in CT claims now turns on occupancy was misrepresented at because a clinic billing the same modifier on 80% of visits put first-party friendly-fraud dispute pack in play. SIU investigator should say what first-party friendly-fraud dispute pack proves.

Decision

SIU investigator in a workers'-comp insurer after a surge in CT claims must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using first-party friendly-fraud dispute pack after a clinic billing the same modifier on 80% of visits.

Hypotheses to test

• The population in first-party friendly-fraud dispute pack is the one a clinic billing the same modifier on 80% of visits named, so Remove access or reverse the item follows for this Payments Fraud file.
• The population in first-party friendly-fraud dispute pack is adjacent only to a clinic billing the same modifier on 80% of visits; Temporary compensating control is the honest Fraud Detection call.
• A workers'-comp insurer after a surge in CT claims already contained a clinic billing the same modifier on 80% of visits before first-party friendly-fraud dispute pack arrived; no new Payments Fraud path.
• Provenance on first-party friendly-fraud dispute pack after a clinic billing the same modifier on 80% of visits is broken; do not pick Remove access or reverse the item or Temporary compensating control yet.

Analysis required

• Quantify loss if the hold is released before first-party friendly-fraud dispute pack is complete.
• Test a one-off dispute against the first edge of a scheme around occupancy was misrepresented at.
• Check mule or round-trip markers in first-party friendly-fraud dispute pack.
• For this Fraud Detection Payments Fraud file, read first-party friendly-fraud dispute pack against a clinic billing the same modifier on 80% of visits and write the one fact that would move occupancy was misrepresented at for SIU investigator.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Payments Fraud packet (first-party friendly-fraud dispute pack after a clinic billing the same modifier on 80% of visits). The follow-on Payments Fraud action is what SIU investigator does next: implement the option, assign an owner, and log the missing fact.