(Updated January 9, 2021): Each year, our attorneys and paralegals review and assess literally thousands of Medicare claims which have been audited (and denied) by Unified Program Integrity Contractors (UPICs) and other contractors working for the Centers for Medicare and Medicaid Services (CMS). Are you preparing for a UPIC audit? If your Medicare or Medicaid claims haven't already been audited by a UPIC, chances are that it will eventually happen. As UPIC audits increase during 2021, it is essential that health care providers and suppliers review their processes to better ensure that services and supplies billed to Medicare and Medicare fully comply with applicable coverage, coding and billing requirements. While defending physicians and other health care providers in UPIC audits and government reviews, we have identified a relatively straight-forward approach for determining whether a particular claim qualifies for coverage and payment. Generally, we refer to this approach as an examination of the “Eight Elements of a Payable Claim.” Notably, this has proven to be extremely helpful tool when developing an effective Compliance Plan for a client. As set out below, physicians and other non-hospital health care providers can often use this approach to determine whether specific services billed to the Medicare and Medicaid programs.
I. Assessing Your Claims -- Preparing for a UPIC Audit:
A discussion of the eight elements which must be carefully assessed for each and every claim is provided below. This is especially when you are preparing for a UPIC audit of the medical services or supplies you have billed to the Medicare and Medicaid programs.
UPIC auditors are excellent at identifying one or more ways in which your claims do not meet applicable coverage requirements. While you may very well disagree with their assessments, especially in “medical necessity” determinations (when you file a request for redetermination appeal and later, a request for reconsideration appeal), you will find that your Medicare Administrative Contractor (MAC) and your Qualified Independent Contractor (QIC) agree with the UPIC's denial decision. Rather than endure significant costs and stress when defending against an overpayment assessment, you need to take steps to avoid a denial in the first place. To that end, health care providers should ensure that clinical staff members are fully trained and educated regarding Medicare’s documentation, coding, and billing processes. It is very important that you show your clinicians that UPICs enforce a strict application of Medicare’s documentation and coverage requirements.
II. Final Considerations -- UPIC Audits:
The likelihood that your practice or organization will be subjected to a Medicare or Medicaid audit is increasing every day. As a participating provider in one or more Federal health care programs, you have an affirmative obligation to ensure that your claims are properly provided, documented, coded, and billed. Unfortunately, many health care providers have never researched and reviewed the proper rules covering the care and treatment services they provide. When conducting a "GAP Analysis"  of your organization, a sample of your claims is an important proactive step you can take to help ensure that your current practices are fully compliant with applicable laws and regulations; such analyses do not have to be statistically significant. Should you identify deficiencies, remedial steps should be taken (immediately) so that future claims for care and treatment will meet all applicable requirements. Keep in mind—any identified overpayments must be repaid promptly to the government in order to avoid possible False Claims Act liability.
Robert W. Liles represents health care providers in UPIC Medicare and Medicaid audits. In addition, Robert counsels clients on regulatory compliance issues, performs GAP analyses, conducts internal reviews, and trains healthcare professionals on various legal and compliance issues Do you need help preparing for a UPIC audit? Call Robert for a free consultation: 1 (800) 475-1906.
-  A detailed discussion of the UPIC audit process can be found at the following link.
-  For an overview of the impact of an "exclusion" action, please see Paul Wiedenfeld's article titled "A Provider's Guide to OIG Exclusions."
-  A detailed discussion of a provider's repayment obligations when an overpayment has been identified can be found at this link.
-  For a detailed discussion on how to conduct a "GAP Analysis" of your health care claims, please see our page titled: "How to Conduct a GAP Analysis of Your Health Care Practice."