Assess whether a provider should be suspended pending SIU (619018)

Situation

The desk packet is check-kiting multi-bank float map after three applications sharing one employer EIN and no payroll. SIU investigator in a Medicare Advantage claims shop has to name Remove access or reverse the item or Temporary compensating control for this Fraud Detection Claims and Benefits Fraud file.

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 check-kiting multi-bank float map after three applications sharing one employer EIN and no payroll.

Hypotheses to test

• Three applications sharing one employer EIN and no payroll is noise around an already-controlled Claims and Benefits Fraud process in a Medicare Advantage claims shop, given check-kiting multi-bank float map.
• Three applications sharing one employer EIN and no payroll is the event in check-kiting multi-bank float map that forces Remove access or reverse the item for SIU investigator under Fraud Detection.
• Check-kiting multi-bank float map shows a one-file miss after three applications sharing one employer EIN and no payroll, not a Claims and Benefits Fraud program failure.
• Check-kiting multi-bank float map cannot decide a provider should be yet after three applications sharing one employer EIN and no payroll; hold is the only Fraud Detection close a Medicare Advantage claims shop can defend.

Analysis required

• Quantify loss if the hold is released before check-kiting multi-bank float map is complete.
• Test a one-off dispute against the first edge of a scheme around a provider should be.
• Check mule or round-trip markers in check-kiting multi-bank float map.
• For this Fraud Detection Claims and Benefits Fraud file, read check-kiting multi-bank float map against three applications sharing one employer EIN and no payroll and write the one fact that would move a provider should be 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 (check-kiting multi-bank float map after three applications sharing one employer EIN and no payroll). Lead with the Fraud Detection option check-kiting multi-bank float map can support after three applications sharing one employer EIN and no payroll, then the two facts that force it, then the Monday action for SIU investigator in a Medicare Advantage claims shop.