Assess whether a SAR narrative is supportable today (f3ba5a)

Situation

After a clinic billing the same modifier on 80% of visits, synthetic identity application cluster 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 synthetic identity application cluster after a clinic billing the same modifier on 80% of visits.

Hypotheses to test

• The population in synthetic identity application cluster is the one a clinic billing the same modifier on 80% of visits named, so Remove access or reverse the item follows for this Payments Fraud file.
• The population in synthetic identity application cluster is adjacent only to a clinic billing the same modifier on 80% of visits; Temporary compensating control is the honest Fraud Detection call.
• A Medicare Advantage claims shop already contained a clinic billing the same modifier on 80% of visits before synthetic identity application cluster arrived; no new Payments Fraud path.
• Provenance on synthetic identity application cluster after a clinic billing the same modifier on 80% of visits is broken; do not pick Remove access or reverse the item or Temporary compensating control yet.

Analysis required

• Test a one-off dispute against the first edge of a scheme around a SAR narrative is.
• Check mule or round-trip markers in synthetic identity application cluster.
• Map typology and hold authority bank BSA/AML case manager actually has in a Medicare Advantage claims shop.
• For this Fraud Detection Payments Fraud file, read synthetic identity application cluster against a clinic billing the same modifier on 80% of visits and write the one fact that would move a SAR narrative is for bank BSA/AML case manager.

Recommendation

A Medicare Advantage claims shop needs a named owner on a SAR narrative is. Assign bank BSA/AML case manager to execute Remove access or reverse the item when synthetic identity application cluster after a clinic billing the same modifier on 80% of visits is complete, or Temporary compensating control when the Payments Fraud packet still lacks the discriminator in synthetic identity application cluster.