UPIC Audit

Unified Program Integrity Contractors (UPIC) Audits

UPIC stands for Unified Program Integrity Contractors. UPICs primary goal is to investigate instances of suspected fraud, waste, and abuse in Medicare or Medicaid claims. UPICs have nearly replaced ZPICs (Zone Program Integrity Contractors) as the primary mechanism for CMS to pursue fraud and abuse audits.

They develop investigations early, and in a timely manner, take immediate action to ensure Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC (Medicare Administrative Contractor). Actions the UPICs take to detect and deter fraud, waste, and abuse in the Medicare program include:

• Investigate potential fraud and abuse for CMS administrative action or referral to law enforcement;
• Conduct investigations in accordance with the priorities established by CPI's Fraud Prevention System;
• Perform medical review, as appropriate;
• Perform data analysis in coordination with CPI's Fraud Prevention System, IDR and OnePI;
• Identify the need for administrative actions such as payment suspensions, prepayment or auto-denial edits, revocations, postpay overpayment determination;
• Share information (e.g. leads, vulnerabilities, concepts, approaches) with other UPICs/ZPICs to promote the goals of the program and the efficiency of operations at other contracts; and
• Refer cases to law enforcement to consider civil or criminal prosecution.

In performing these functions, UPICs may, as appropriate:

• Request medical records and documentation;
• Conduct interviews with beneficiaries, complainants, or providers;
• Conduct site verification;
• Conduct an onsite visit;
• Identify the need for a prepayment or auto-denial edit;
• Institute a provider payment suspension; and
• Refer cases to law enforcement.

Who is at Risk for UPIC Audit?

While some think UPIC audit selection is arbitrary, it’s usually based on two things: consumer complaints or data analysis. Consumer complaints usually come from employees or their beneficiaries. Data Analysis, however, will uncover: patients with extended home healthcare visits, patients with long stays in hospice care, or acute care facilities with either a large number of cases or an unusual mix of cases.

How to Prepare for a UPIC Audit

First, learning that your organization is being subjected to a UPIC Audit isn’t an accusation; it’s merely an investigation to ensure fraud hasn’t occurred. But it’s important to implement the following to reduce any potential red-flag occurrences. If a UPIC Audit should occur, implementing the following will help you answer questions, provide appropriate documentation, and maintain accountability:

Implement an Effective Plan

• Make sure you fully understand each of the regulatory and statutory provisions related to the services you bill to Medicare.
• Ensure all of your coding, documentation and billing practices adhere to these rules.
• If you discover any inconsistencies, remedy them immediately, and make sure the plan addresses how these will be prevented in the future.

Never Ignore any Requests for UPIC Documents

• Reply promptly to any documentation requests by your UPIC.
• Failure to do so could result in your organization’s suspension from participation in the Medicare program.

Educate Your Staff on Medicare Coding and Billing Requirements

• Explain all requirements in full so that your staff can properly do their job when they bill Medicare.  Preventing mistakes up front is a much better strategy than having to deal with the fallout of mistakes later.
• If you think you may be a candidate for a UPIC Audit, these tips should help you get things in order.  Remember that Medicare regulations are a vast, expansive minefield that are not easy to navigate.  An experienced health law attorney is a great resource to have on your side in the event of a UPIC Audit.