Assess whether a provider should be suspended pending SIU after three

Situation

After three applications sharing one employer EIN and no payroll, ACH return-reason code R10 spike is what bank BSA/AML case manager can touch in a Medicare Advantage claims shop. Fraud Detection will live with Remove access or reverse the item versus Temporary compensating control on this Payments Fraud file.

Decision

Bank BSA/AML case manager in a Medicare Advantage claims shop must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using ACH return-reason code R10 spike after three applications sharing one employer EIN and no payroll.

Hypotheses to test

• ACH return-reason code R10 spike reads as Remove access or reverse the item once three applications sharing one employer EIN and no payroll is lined up to the same Fraud Detection population.
• ACH return-reason code R10 spike is closer to Temporary compensating control after three applications sharing one employer EIN and no payroll; Remove access or reverse the item would over-claim this Payments Fraud extract.
• Approve a documented exception is still live in ACH return-reason code R10 spike for bank BSA/AML case manager in a Medicare Advantage claims shop.
• ACH return-reason code R10 spike is missing the fact bank BSA/AML case manager needs after three applications sharing one employer EIN and no payroll; stop this Fraud Detection close.

Analysis required

• Trace funds, counterparties, and reversals in ACH return-reason code R10 spike through the window opened by three applications sharing one employer EIN and no payroll.
• Quantify loss if the hold is released before ACH return-reason code R10 spike is complete.
• Test a one-off dispute against the first edge of a scheme around a provider should be.
• For this Fraud Detection Payments Fraud file, read ACH return-reason code R10 spike against three applications sharing one employer EIN and no payroll and write the one fact that would move a provider should be for bank BSA/AML case manager.

Recommendation

Choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold on this Fraud Detection / Payments Fraud packet (ACH return-reason code R10 spike after three applications sharing one employer EIN and no payroll). If ACH return-reason code R10 spike cannot force a Fraud Detection label under Payments Fraud, stop. If ACH return-reason code R10 spike after three applications sharing one employer EIN and no payroll cannot support Remove access or reverse the item versus Temporary compensating control on this Fraud Detection Payments Fraud close, bank BSA/AML case manager must do not infer a control or scheme beyond the transaction and entitlement evidence.