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Dashboard Define Assess Respond Report     Scenario Assessment Scenario: Description: Path: Provider Compliance - Submission of Accurate Claims and Information > Billing - Patient not present   Assessment     Risk Assessment (edit) 1. Likelihood ProbableReasonably PossibleRemote   2. Significance HighModerateLow   3. Inherent Risk HighModerateLow   4. Control Effectiveness WeakFairModerateStrongVery Strong   5. Concealment Risk HighModerateLow   6. Scenario Red Flags Risk HighModerateLow   7. Residual Risk HighModerateLow       Likelihood   Category Rating Narrative Historical Industry Trends Interviews Corporate Culture Business Function Management Control Environment Likelihood Reasonably Possible   Significance   Category Rating Narrative Revenue/Earnings Risk Regulatory/Compliance Risk Reputation Risk Financial Loss Risk Financial Statement Risk Credit Risk Operational Risk Significance High   Controls Effectiveness Control Control Type Control Value Control Evaluation Separation of Duties Evaluation Control Effectiveness Control Effectiveness Narrative 1. Reconcile Patient Files to Billing Records Detect - Hard High Moderate Fair Moderate 2. Billing Records Reconciled to Payments Received Detect - Hard Superior Weak Weak Weak   Concealment Risks Concealment Concealment Likelihood Controls Effectiveness Concealment Red Flags Risk Concealment Risk Narrative 1. Fictitious patient payments diverted to secondary bank accounts 2. Fictitious patient claims processed on secondary system Scenario Red Flags Risk   Red Flag Area Type Frequency Risk Risk Narrative Patient File Missing Moderate Moderate Patients receiving routine treatment live signficantly outside of service area Patient File Does Not Agree with Billing Records Moderate Moderate Insured's address on claim form is the same as provider

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