About 20% of United States tax dollars are spent on heathcare.  Naturally, reducing improper payments has been a priority of CMS. Thus, all medical practice managers and healthcare providers should be aware of CMS’s process of contracting with Uniform Program Integrity Contractors (UPIC’s), private entities hired by CMS Health-Audit-300x200to audit providers suspected of fraud. UPIC contracts combine Zone Program Integrity Contractors (ZPIC’s) and Medicaid Integrity Contractors (MIC’s) to coordinate Medicare and Medicaid auditing. UPIC’s focus primarily on Medicare claims, and seek to distinguish between provider billing errors or fraud.

UPIC Audit Lawyers

Our business and healthcare law firm follows legal trends in the healthcare industry.  UPIC’s are private sector organizations that review Medicare claims in order to assist the government in recovering overpayments to healthcare providers.  UPIC audits are often generated through data analysis or by review of consumer complaints and most often target specific healthcare providers. UPIC’s conduct screening, medical reviews, and investigations, while also implementing remedies and collaborating with state and local governments to ensure compliance with payment guidelines. UPIC’s are organized regionally, with Georgia and South Carolina falling in District 4 and managed by Safeguard Services.  In recent years, home health agencies, DME companies, therapy clinics, and laboratories have been targets for fraud investigations through extensive audits.

A UPIC audit can result in payment suspension to the provider once there is reliable information that overpayment exists, incorrect payments have been made, or when there is a credible allegation of fraud. Payment suspension has created controversy in recent years, since credible allegations of fraud permit the UPIC to take administrative action immediately. Credible allegations of fraud are defined by 42 C.F.R. § 405.370(a)  as an allegation from any source, including but not limited to fraud hotline complaints, claims data mining, patterns identified through provider/supplier audits, civil false claims cases, and law enforcement investigations. Additionally, allegations are considered credible when they have an “indication of reliability.”

Once payments have been suspended, an appeals process may follow. The CMS Manual System  outlines some of the process of navigating through a UPIC audit. Consulting an experienced attorney can mitigate headache and additional issues that may arise down the road as you navigate through the appeals process.



Steps in Navigating Through Payment Suspension: 

  • Often, suspensions occur without notice. Sometimes, providers may receive a probe audit of up to 10 claims. Often, the probe audit is what gives rise to the payment suspension.
  • If prior notice is received which indicates that a payment suspension will occur, the provider has 15 days to rebut.
  • Within 15 days of receiving the rebuttal, the contractor is required to respond to the rebuttal. Then, CMS will determine if the suspension should be removed or remain in place. Most suspensions stay in place.
  • Initial payment suspension can last up to 180 days, with up to two 180 day extension periods that are not appealable.
  • During a period of payment suspension, a supplier may still provide services and submit claims. Instead of the claims being paid to the provider, the payments are temporarily moved to an escrow account that is managed by the UPIC.
  • Upon any finding of fraud, the UPIC will direct its findings to the Department of Justice or Office of the Inspector General, who will submit recommendations and their findings of overpayments.
  • Any overpayment that is discovered is taken from the escrow account upon conclusion of the case. Any remaining balance would return to the practice.
  • The healthcare provider may appeal identified overpayments through the Medicare administrative appeals process.

Healthcare providers can take precautions within their practice to avoid being subject to an audit. By communicating with staff, identifying potential problem areas, regularly conducting internal reviews of billing claims, and consulting an experienced attorney about their billing practices, providers can be better prepared for audits.


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**Disclaimer: Thoughts shared here do not constitute legal advice. Please consult with an attorney to discuss your legal issue.

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