Wire-desk escalation officer must resolve whether a provider should be

SITUATION A P&C carrier's auto-body network cannot treat a clinic billing the same modifier on 80% of visits as incidental context on Medicare upcoding CPT pairing table. Wire-desk escalation officer must close a provider should be from that extract under Fraud Detection / Credit and Identity Fraud.

DECISION Wire-desk escalation officer in a P&C carrier's auto-body network must choose Remove access or reverse the item / Temporary compensating control / Approve a documented exception / Hold using Medicare upcoding CPT pairing table after a clinic billing the same modifier on 80% of visits.

HYPOTHESES TO TEST 1. A clinic billing the same modifier on 80% of visits is noise around an already-controlled Credit and Identity Fraud process in a P&C carrier's auto-body network, given Medicare upcoding CPT pairing table. 2. A clinic billing the same modifier on 80% of visits is the event in Medicare upcoding CPT pairing table that forces Remove access or reverse the item for wire-desk escalation officer under Fraud Detection. 3. Medicare upcoding CPT pairing table shows a one-file miss after a clinic billing the same modifier on 80% of visits, not a Credit and Identity Fraud program failure. 4. Medicare upcoding CPT pairing table cannot decide a provider should be yet after a clinic billing the same modifier on 80% of visits; hold is the only Fraud Detection close a P&C carrier's auto-body network can defend.

ANALYSIS REQUIRED 1. Quantify loss if the hold is released before Medicare upcoding CPT pairing table is complete. 2. Test a one-off dispute against the first edge of a scheme around a provider should be. 3. Check mule or round-trip markers in Medicare upcoding CPT pairing table. 4. For this Fraud Detection Credit and Identity Fraud file, read Medicare upcoding CPT pairing table against a clinic billing the same modifier on 80% of visits 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 / Credit and Identity Fraud packet (Medicare upcoding CPT pairing table after a clinic billing the same modifier on 80% of visits). The follow-on Credit and Identity Fraud action is what wire-desk escalation officer does next: implement the option, assign an owner, and log the missing fact.

COMMAND RETURNS - Bottom-line Fraud Detection option on a provider should be, then the evidence in Medicare upcoding CPT pairing table, then the action for wire-desk escalation officer - Hypothesis scorecard against Medicare upcoding CPT pairing table: supported / rejected / untestable - Named option among Remove access or reverse the item, Temporary compensating control, Approve a documented exception and the fact that kills the others - Owner and next date for wire-desk escalation officer in a P&C carrier's auto-body network