Whether a provider's attendance is fabricated from EBT out-of-state

Situation

A provider billing full-time care during school hours put EBT out-of-state redemption cluster in front of child-care provider integrity lead in a Medicaid agency with a surge in MAGI mismatches. This Public Benefits / Trafficking and Eligibility Fraud close is a provider's attendance is from EBT out-of-state redemption cluster, and the live options are Pay or continue, Recoup, Deny.

Decision

Child-care provider integrity lead in a Medicaid agency with a surge in MAGI mismatches must choose Pay or continue / Recoup / Deny / Hold using EBT out-of-state redemption cluster after a provider billing full-time care during school hours.

Hypotheses to test

• EBT out-of-state redemption cluster reads as Pay or continue once a provider billing full-time care during school hours is lined up to the same Public Benefits population.
• EBT out-of-state redemption cluster is closer to Recoup after a provider billing full-time care during school hours; Pay or continue would over-claim this Trafficking and Eligibility Fraud extract.
• Deny is still live in EBT out-of-state redemption cluster for child-care provider integrity lead in a Medicaid agency with a surge in MAGI mismatches.
• EBT out-of-state redemption cluster is missing the fact child-care provider integrity lead needs after a provider billing full-time care during school hours; stop this Public Benefits close.

Analysis required

• Trace the notice and appeal path child-care provider integrity lead must preserve.
• Test eligibility, recoupment, and improper-payment facts in EBT out-of-state redemption cluster after a provider billing full-time care during school hours.
• Quantify overpayment if a provider's attendance is is wrong.
• For this Public Benefits Trafficking and Eligibility Fraud file, read EBT out-of-state redemption cluster against a provider billing full-time care during school hours and write the one fact that would move a provider's attendance is for child-care provider integrity lead.

Recommendation

Choose Pay or continue / Recoup / Deny / Hold on this Public Benefits / Trafficking and Eligibility Fraud packet (EBT out-of-state redemption cluster after a provider billing full-time care during school hours). The follow-on Trafficking and Eligibility Fraud action is what child-care provider integrity lead does next: implement the option, assign an owner, and log the missing fact.