UPIC Audits are Here! Are You Prepared for an Audit by Medicare’s Newest Program Integrity Contractor?

UPIC Audits are Expanding Throughout the Country as the Transition from the ZPIC Program Continues.In an effort to avoid duplication of program integrity efforts and better integrate Medicare and Medicaid audits and investigations under a single contractor in a specific jurisdiction. CMS has contracted with a number of new private sector organizations to serve as Unified Program Integrity Contractors (UPICs).  As set out below, Medicare and Medicaid providers and suppliers are now starting to receive UPIC medical records requests and the number of UPIC audits are increasing each month.  CMS has described the purpose of the UPIC program as follows:

"The Unified Program Integrity Contractors (UPICs) perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States. Specifically, the UPIC’s perform integrity related activities associated with Medicare Parts A, B, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), Medicaid, and the Medicare-Medicaid data match program (Medi-Medi). The UPIC contracts operate in five (5) separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the Zone Program Integrity Contractor (ZPIC), Program Safeguard Contractor (PSC) and Medicaid Integrity Contractor (MIC) contracts." (emphasis added)

Simply put, the purpose of the UPIC program is to consolidate the work currently being performed by various Medicare and Medicaid program integrity contractors under a single private sector contractor.  Each UPIC will be responsible for handling federal level program integrity audits for both Medicare and Medicaid within a defined geographic area (typically comprised of multiple states).

In July 2013, CMS released a Request for Information and solicited vendor comments regarding the possible requirements for combining Medicare and Medicaid program integrity functions.  The contracting process culminated in the award of UPIC contracts to the following private sector contractors on in May 2016:

Each UPIC Contract Has Now Been Awarded and UPIC Audits Have Been Initiated in Several Jurisdictions.

  • Health Integrity, LLC (Western Jurisdiction)
  • AdvanceMed Corporation (Midwestern Jurisdiction)
  • IntegriGuard, LLC, dba HMS Federal (Indefinite Delivery Indefinite Quantity)
  • Noridian Healthcare Solutions, LLC (Indefinite Delivery Indefinite Quantity)
  • Safeguard Services LLC (North Eastern Jurisdiction)
  • StrategicHealthSolutions, LLC (Indefinite Delivery Indefinite Quantity)
  • TriCenturion, Inc. (Indefinite Delivery Indefinite Quantity)

Once fully implemented, the UPIC program integrity strategy will greatly enhance the ability of CMS to identify aberrant billing patterns and practices, especially those that involve both Medicare and Medicaid claims.

Now, more than ever, it is essential that all health care providers participating in the Medicare and / or Medicaid programs ensure that they have developed and implemented an effective Compliance Program. As we have discussed in other articles, it is essential that Medicare and Medicaid providers and suppliers analyze the services and supplies being provided and ensure that applicable medical necessity requirements are met, the claim qualifies for coverage and payment, and the services / supplies are fully documented (as set out in LCDs and other guidance).  Additionally, providers and suppliers need to ensure that any claims billed to Medicare or Medicaid have been properly coded and billed.  Simply put, health care providers and suppliers – must regularly monitor and review their practices to verify that all regulatory and statutory requirements which cover a particular claim have been met prior to billing Medicare or Medicaid for the services or supplies at issue.  For a detailed discussion of the collateral adverse consequences that may result from UPIC audits, see the following article on "UPIC Referrals to State Licensure Boards."

If your medical practice, home health agency, hospice, pain clinic, addiction treatment facility or DME company is being audited by a UPIC, give us a call.  For a free consultation regarding UPIC audits, we can be reached at:  (800) 475-1906.