Assess whether to refer to law enforcement or keep civil (14e4b5)

SITUATION The working file is straw-buyer occupancy file after three applications sharing one employer EIN and no payroll. SIU investigator in a Medicare Advantage claims shop has to name To refer to law enforcement or Keep civil for this Fraud Detection Claims and Benefits Fraud file.

DECISION SIU investigator in a Medicare Advantage claims shop must choose To refer to law enforcement / Keep civil using straw-buyer occupancy file after three applications sharing one employer EIN and no payroll.

HYPOTHESES TO TEST 1. Straw-buyer occupancy file reads as To refer to law enforcement once three applications sharing one employer EIN and no payroll is lined up to the same Fraud Detection population. 2. Straw-buyer occupancy file is closer to Keep civil after three applications sharing one employer EIN and no payroll; To refer to law enforcement would over-claim this Claims and Benefits Fraud extract. 3. A dual reading is still live in straw-buyer occupancy file for SIU investigator in a Medicare Advantage claims shop. 4. Straw-buyer occupancy file is missing the fact SIU investigator needs after three applications sharing one employer EIN and no payroll; stop this Fraud Detection close.

ANALYSIS REQUIRED 1. Quantify loss if the hold is released before straw-buyer occupancy file is complete. 2. Test a one-off dispute against the first edge of a scheme around to refer to law. 3. Check mule or round-trip markers in straw-buyer occupancy file. 4. For this Fraud Detection Claims and Benefits Fraud file, read straw-buyer occupancy file against three applications sharing one employer EIN and no payroll and write the one fact that would move to refer to law for SIU investigator.

RECOMMENDATION Choose To refer to law enforcement / Keep civil on this Fraud Detection / Claims and Benefits Fraud packet (straw-buyer occupancy file after three applications sharing one employer EIN and no payroll). Lead with the Fraud Detection option straw-buyer occupancy file 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.

COMMAND RETURNS - Bottom-line Fraud Detection option on to refer to law, then the evidence in straw-buyer occupancy file, then the action for SIU investigator - Hypothesis scorecard against straw-buyer occupancy file: supported / rejected / untestable - Claims and Benefits Fraud finding in straw-buyer occupancy file that a second reviewer can re-perform - Missing page in straw-buyer occupancy file after three applications sharing one employer EIN and no payroll, if any