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Rise of the UPICs – Changes to the Medicare Program Integrity Contractor Landscape are on the Horizon

(August 16, 2013): In an effort to streamline the often-confusing audit structure of multiple Medicare and Medicaid contractors (many of which have overlapping responsibilities and jurisdictions), the Centers for Medicare and Medicaid Services (CMS) is reportedly preparing to establish a new consolidated program integrity contractor, to be known as a Unified Program Integrity Contractor (UPIC).  These changes are intended to combine the integrity duties currently undertaken by Zone Program Integrity Contractors (ZPICs) and Medicare Administrative Contractors (MACs).  Notably, MACs will continue to operate but their program integrity responsibilities will be largely transferred over to this new contractor with consolidated auditing duties.

I.  Program Integrity Contractor Duties of the UPIC:

As noted in CMS’ Request for Information (RFI), the Center for Program Integrity (CPI) plans to establish multiple regional UPICs (between five and fifteen).

The UPIC (“the Contractor”) shall work on a wide variety of activities that focus on identifying and reducing fraud, waste, and abuse by individuals and entities furnishing items and services (hereafter, for convenience, referred to as “providers”) under the Medicare and Medicaid programs.  (Page 3). 

II.   Anticipated UPIC Priorities:

The primary priority areas to be pursued by UPICs are anticipated to include cases involving:

  • Patient abuse or harm;
  • Ability to prevent future fraud, waste or abuse by taking administrative actions to remove providers or suppliers from the affected Program, or otherwise prevent inappropriate future payments;
  • Multi-State fraud;
  • High dollar amounts of potential overpayments;
  • Likelihood for an increase in the amount of fraud or enlargement of a pattern, including
    the potential that findings can be used to refine CMS’s anti-fraud prevention efforts and analytic models;
  • Fraud complaints made by Medicare supplemental insurers;
  • Law enforcement requests for assistance that involve court-imposed deadlines;
  • Law enforcement requests for assistance in ongoing investigations that involve interagency initiatives or projects;
  • Law enforcement requests for early administrative actions to prevent or mitigate losses to the affected Program(s); and,
  • Other new elements that may be identified by CMS through technical direction.(Page 5)

III.  Conclusion: 

On the positive side, the UPIC program is likely to go a long way towards streamlining the audit process and reducing the number of duplicative audit requests received from competing program integrity contractors.  In any event, CMS’ consolidation of these program integrity contractor duties is yet another clear indication that the government intends improve its efficiency in scrutinizing questionable Medicare and Medicaid billings. We strongly encourage all health care providers (not merely those participating in the Medicare and / or Medicaid programs) to develop and implement an effective Compliance Plan and overall Compliance Program.  Participating providers have an obligation to keep up with and follow all applicable statutory and regulatory requirements associated with Medicare and Medicaid services.  Now is the time to conduct a “GAP ANALYSIS” of your current practices so that any needed remedial actions can be taken.

Healthcare LawyerRobert W. Liles, JD, MBA, MS, serves as Managing Partner at Liles Parker, a boutique health law firm representing health care providers around the country in connection with audits, investigations, compliance and transactional health care projects.  For a free consultation regarding your case, please give Robert a call.  He can be reached at:  1 (800) 475-1906.

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