“We received a request for medical records from Qlarant, who apparently is contracted with Medicare to review records for medical (and, of course, payment) necessity. In this case, they’ve asked for chart notes for ten different patients, one date of service for each patient. We’ve never been subjected to this type of review previously and want to do everything possible to make sure that we submit the appropriate and sufficient records and that we submit them in the appropriate manner. Obviously, we’re also concerned that this inquiry is a fishing expedition that could trigger some larger audit. Is there any advice that you can provide that might help us through this process? In our review of the records that were requested we did notice a few minor billing errors, but we believe that the records substantiate payment for all treatment that was performed.”
This is a UPIC Audit. Qlarant is a UPIC contractor.
What exactly is a UPIC Audit? Unified Program Integrity Contractor Audits.
CMS established the UPICs to consolidate program integrity activities formally performed by the Zone Program Integrity Contractors (ZPICs), Program Safeguard Contractors (PSCs), and Medicaid Integrity Contractors. As a result, UPICs are the only program integrity contractors that monitor both the Medicare fee-for-service (FFS) and Medicaid programs. UPICs are responsible for identifying and protecting against fraud, waste, and abuse using both pre-payment medical reviews and post-payment audits. UPIC audits should be taken very seriously as they can result in high-dollar extrapolated overpayment demands, payment suspensions, and referral to law enforcement for additional review.
What triggers a UPIC audit?
According to CMS, CMS often receives referrals of improper payments from MACs, UPICs and other investigative agencies.
UPICs primary goal is to investigate instances of suspected fraud, waste and abuse in Medicare or Medicaid claims.
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 not to be recouped by the Medicare Administrative Contractor.
UPICs do the following:
Investigate potential fraud and abuse of 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, post-pay overpayment determination.
Share information (e.g. leads, vulnerabilities, concepts, approaches) with other UPICs/ZIPCs to promote the goals of the program and the efficiency of operations at other contracts.
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.
Refer cases to law enforcement.
My advice to the providers when a UPIC Audit is initiated is to contact your malpractice insurance carrier and find out if you have administrative defense coverage. This insurance/coverage should cover you when you are audited. PICA certainly has this coverage for their insured providers. If your malpractice insurance carrier does not provide administrative defense coverage, it would behoove you to contact a health care attorney. The provider certainly does not need to interact with the UPIC auditor directly. Remember, “anything that you say can be held against you.”
This is my opinion.
Michael G. Warshaw, DPM, CPC
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