UPIC Audits: What They Are & How We Can Help

The Medicare program has come under fire for approving inappropriate payments to device suppliers and health care providers. Their efforts to prevent or correct inappropriate payments has resulted in a higher number of billing audits. When billing mistakes are found, Medicare takes back their original payment. These audits run the risk of putting providers on the hook for previously-approved procedures, but the highest level of audit investigation risks far more than that.

Zone Program Integrity Contractors, or ZPICs, are Medicare auditors who specialize in investigating fraud, waste, and abuse. Each UPIC—there are 7 nationwide—is responsible for detecting and deterring Medicare fraud within their “zone.” Providers are chosen based on data analysis, complaints, and referrals. ZPICs are authorized to use statistical tools to assess the likelihood that your organization is committing fraud.

Initial investigation begins when your services are audited for fraud likelihood—i.e. if you’re a hospice care provider, then abnormal length of stay will trigger a UPIC audit. The UPIC will notify you when you’re under investigation, but they have the authority to make unannounced visits at any point during the audit, interview management and staff, and can recommend your exclusion from the Medicare program.

How Our Houston Medicare Fraud Attorneys Can Help

Suppliers and providers have one task during a UPIC audit—establish that no fraud occurred. Regardless of billing mistakes, proving the absence of fraud (or supplying sufficient evidence to stem accusations of fraud) prevents the UPIC from turning your case over to the Department of Justice (DOJ) or the Office of the Inspector General (OIG).

The only way to protect yourself from fraud investigation and Medicare exclusion is through airtight documentation, drafting clear and executable policies, and ensuring that your practices are demonstrably compliant. The legal team at Hendershot Cowart P.C. has spent more than 150 years combined helping health care organizations protect themselves from Medicare investigations.

Our Houston Medicare fraud lawyers are familiar with preparing businesses for regulatory audits, as well as defending them from agencies who work to fine them without evidence of wrongdoing. We also have decades of experience with health care compliance. In short, there’s no firm more equipped to help protect you from a UPIC audit.

Call us at (713) 909-7323 or contact us online to learn about what you need to ensure long-term success and compliance.


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