Assess whether a provider should be suspended pending SIU (0cd74b)

Situation

Claims and Benefits Fraud work in a workers'-comp insurer after a surge in CT claims now turns on a provider should be because a claims photo EXIF timestamp that predates the loss put first-party friendly-fraud dispute pack in play. Wire-desk escalation officer should say what first-party friendly-fraud dispute pack proves.

Decision

Wire-desk escalation officer 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 claims photo EXIF timestamp that predates the loss.

Hypotheses to test

• A claims photo EXIF timestamp that predates the loss is noise around an already-controlled Claims and Benefits Fraud process in a workers'-comp insurer after a surge in CT claims, given first-party friendly-fraud dispute pack.
• A claims photo EXIF timestamp that predates the loss is the event in first-party friendly-fraud dispute pack that forces Remove access or reverse the item for wire-desk escalation officer under Fraud Detection.
• First-party friendly-fraud dispute pack shows a one-file miss after a claims photo EXIF timestamp that predates the loss, not a Claims and Benefits Fraud program failure.
• First-party friendly-fraud dispute pack cannot decide a provider should be yet after a claims photo EXIF timestamp that predates the loss; hold is the only Fraud Detection close a workers'-comp insurer after a surge in CT claims can defend.

Analysis required

• Trace funds, counterparties, and reversals in first-party friendly-fraud dispute pack through the window opened by a claims photo EXIF timestamp that predates the loss.
• 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 a provider should be.
• For this Fraud Detection Claims and Benefits Fraud file, read first-party friendly-fraud dispute pack against a claims photo EXIF timestamp that predates the loss and write the one fact that would move a provider should be for wire-desk escalation officer.

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 (first-party friendly-fraud dispute pack after a claims photo EXIF timestamp that predates the loss). The follow-on Claims and Benefits Fraud action is what wire-desk escalation officer does next: implement the option, assign an owner, and log the missing fact.