What is a UPIC Audit and How Serious is this Audit?

What are the Most Common Medicare and Medicaid Audits?

•      • Types of Medicare and Medicaid audits include:
•      • Targeted Probe & Educate (TPE) Program audits.
•      • Unified Program Integrity Contractor (UPIC) audits.
•      • Supplemental Medical Review Contractor (SMRC) audits.
•      • Comprehensive Error Rate Testing (CERT) audits.
•      • Recovery Audit Contractor (RAC) audits.

Auditors: Who should we fear the most?

Unified Program Integrity Contractor (UPIC) 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

This is my opinion.

Michael G. Warshaw

DPM, CPC