Medicare UPIC Audit Defense Lawyers in Houston
Unified Program Integrity Contractors Audits
The Centers for Medicare & Medicaid Services (CMS) created the Unified Program Integrity Contractors (UPIC) program to investigate suspected fraud and abuse associated with Medicare Parts A and B, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), and Medicaid.
UPICs, such as Qlarant and Safeguard Services, use data analysis, referrals from other CMS contractors or investigative agencies, and even direct complaints from consumers or disgruntled employees to identify and investigate providers who may be inadvertently or intentionally committing fraud, waste, or abuse of Medicare Trust Fund monies.
All providers who seek reimbursement from Medicare or Medicaid are subject to UPIC audits.
On This Page
- What Is the Difference Between UPIC and ZPIC?
- What Triggers a Medicare UPIC Audit?
- What to Expect from a Medicare UPIC Audit
- What Are the Possible Consequences of a Medicare UPIC Audit?
- Who Are the Medicare UPIC Contractors?
- What Should I Do If I Receive a Letter From a UPIC?
- Do I Need a Lawyer to Respond to a UPIC Audit?
- Defending Medicare Providers and DME Suppliers Against UPIC Audits
- Put Proven Lawyers on Your Side
Before UPICs, the Zone Program Integrity Contractor (ZPIC) program was responsible for performing fraud, waste, and abuse detection, deterrence, and prevention activities for CMS. In 2016, CMS began to transition to the UPIC program over several years as ZPIC contracts expired. Today, UPIC has assumed all functions previously performed by the ZPIC program.
Billing mistakes and overpayment can easily trigger a UPIC audit, especially for hospice care, home health agencies, long-term care, and durable medical equipment (DME) providers. Make sure you are billing Medicare correctly and maintaining the required documentation.
Errors in level-of-care billing and coding can also trigger a UPIC audit, so ensure that your inpatient stays are coded correctly.
Other triggers for UPIC audits include:
- Having a greater frequency of high-end services compared to local or national patterns
- Billing trends that fall outside of the industry standard
- Long inpatient stays (hospice providers and long-term care providers are most at risk)
- Claim records that do not match doctor’s records
- Medical records that tend to have obvious or nearly identical documentation
- Any improper or inaccurate Medicare billing
- Complaints to the OIG
- Referrals from other government contractors (RACs or MACs) or investigative agencies
- OIG and FBI inquiries
Perform internal audits regularly to catch potential triggers and double-check that your medical records comply with state and federal regulations. They should be patient-specific, legibly signed by the rendering provider, and note the intent to order services and procedures, among other medical record documentation requirements.
UPICs do not conduct random audits. They initiate focused reviews, medical record requests, and interviews to gather evidence and establish the facts in suspected cases of fraud, waste, or abuse.
When investigating a provider, a UPIC auditor may:
- Request medical records and documentation
- Conduct interviews with beneficiaries, complainants, or providers
- Visit your practice
- Identify the need for a prepayment or auto-denial edit
- Institute a provider payment suspension
- Refer potential fraud cases to law enforcement
UPICs evaluate medical records for evidence of alterations, such as missing pages, inserted pages, or unsigned and undated handwritten notes in margins. They look for patterns or trends, such as overuse of high-end codes or billing for more hours of care than would normally be expected. And they will conduct interviews to verify that services or equipment were provided as claimed.
The focus of the UPIC audit is to determine the extent of the alleged fraud, waste, or abuse; and take any appropriate action to protect Medicare Trust Fund dollars.
If a UPIC audit detects Medicare or Medicaid fraud, the consequences can be devastating. Providers can face administrative actions such as payment suspensions, prepayment or auto-denial edits, revocations, or recoupment.
For some practices, like hospice centers, this can tip tight operating margins in the wrong direction and lead to bankruptcy.
Additionally, unfavorable UPIC audits can be referred to the Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), and other federal investigative agencies. These investigations can result in more serious civil penalties and even criminal charges
UPIC auditors are businesses that have contracts with CMS. When you are dealing with a UPIC auditor, you are not dealing with CMS directly.
CMS divided its UPIC contracts into five separate geographical zones:
- Western Jurisdiction: AK, AZ, CA, HI, ID, MN, NV, ND, OR, SD, UT, WA, WY, American Samoa, Northern Marianas Islands and Guam. The UPIC for this region is Qlarant Integrity Solutions.
- Southwestern Jurisdiction: CO, NM, OK, TX, AR, LA, and MS. Again, the UPIC is Qlarant Integrity Solutions.
- The Southeastern Jurisdiction is awarded to Safeguard Services LLC and includes: AL, FL, GA, NC, PR, SC, TN, U.S. Virgin Islands, VA and WV.
- Northeastern Jurisdiction: ME, VT, NH, MA, RI, CT, NY, PA, NJ, DE, MD, DC, and the counties of Arlington and Fairfax and the city of Alexandria in Virginia. The UPIC is SafeGuard Services, LLC.
- Midwestern Jurisdiction: IL, IN, IA, KS, KY, MI, MN, MO, NE, OH and WI. CoventBridge is the UPIC for this region.
Qlarant, Safeguard, and other UPIC auditors are not interested in helping you; they are interested in aggressively rooting out evidence of waste and abuse to preserve their government contracts.
You need someone on your side, too. Do not hesitate to consult a lawyer.
If you receive a letter from a UPIC, you are already under investigation. This is no ordinary Medicare audit. Your case has been escalated, so handle allegations and requests for information seriously.
Do not ignore the letter. Instead, retain an attorney to help you reply promptly to document requests.
UPIC audits can subject providers and medical businesses to considerable expenses, lost productivity, and the potential for recoupment. Auditors can also refer allegations of healthcare fraud for civil or criminal investigation and prosecution.
Your attorney can help you present the requested documentation – on time and within the requested parameters – and help protect you from fraud, waste, or abuse allegations that could open you up to further investigations from the OIG, FBI, or Department of Justice.
UPIC audits can take six months or longer, and you may be ineligible to get CMS reimbursement during this time. As a result, UPIC audits can and do put providers out of business. Unfavorable outcomes from UPIC audits may not be resolved immediately, and providers can suffer financially while the matter is appealed.
The Medicare appeals process is burdensome, and time deadlines are strictly adhered to. Miss a deadline and you will be left without recourse.
Instead, resolve your UPIC audit as quickly and advantageously as possibly with the advice of proven legal counsel. You only get one chance to present your records and tell your side of the story.
Your lawyer can help you avoid deficiencies in the documentation and present them to a UPIC auditor efficiently and on time. An experienced healthcare attorney can also work to prevent your case from being referred to law enforcement agencies, such as the OIG.
Our goal when representing clients in UPIC matters is to safeguard clients from liabilities. We achieve this through:
- Proactive audit prevention for new and existing practices
- Comprehensive compliance and self-auditing plans
- Communication and negotiation with auditors
- Executive and employee interview preparation
- Document preservation and production
- Guidance through the Medicare appeals process
- Assistance with subpoenas, CIDs, and OIG investigations
CMS fraud is illegal and has serious consequences, and UPIC audits are relentless. UPIC audits can also uncover other regulatory violations, so be vigilant about regulatory compliance to avoid Medicare audits.
Hendershot Cowart P.C. delivers immediate responsive representation to clients facing Medicare audit or fraud investigations. Our skilled healthcare law attorneys have more than 100 years of collective legal experience and can rigorously defend you in a Medicare UPIC audit.
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