One of the most destructive types of audits that a Medicare provider can suffer from a Medicare contractor is a UPIC audit. A UPIC (Unified Program Integrity Contractor) is a type of Medicare contractor that combines several program integrity functions that were previously handled by different entities. The primary goal of the UPICs is to identify potential fraud; however, they are often quick to accuse providers of significant fraud and bring devastating consequences to providers without giving the providers an opportunity to respond. Even a UPIC audit for a relatively small number of claims or a relatively small dollar value should be treated as a significant investigation.
A UPIC may initiate an investigation based on several types of leads. The UPICs are authorized to use analysis of claims data to identify potential billing irregularities or suspected fraud, and this is the most frequent source of a UPIC investigation. This means that providers with unusual billing patters or high utilization are inherently more susceptible to UPIC investigations, even if these billing practices are for entirely legitimate reasons, such as a particular patient population. The UPICs may also receive referrals from other agencies and from outside sources, such as news media, interviews, or beneficiary complaints.
Once a UPIC initiates an investigation, it has many tools at its disposal. It may utilize records requests, onsite reviews at the place of business of the provider or supplier, or interviews of employees of the provider or supplier. Often UPIC audits begin as small probe audits, possible only a dozen claims valued at a few thousand dollars. These small probe audits may at first appear to be not worth defending or appealing. However, UPICs often use the results of these small probe audits to jump to the conclusion that the provider is committing fraud and, seemingly out of nowhere, suspend the provider’s Medicare payments. The UPIC may also persuade the Centers for Medicare & Medicaid Services (CMS) to revoke the provider’s Medicare billing privileges because the UPIC’s probe audits have made it appear as though the provider has a pattern of submitting claims that do not meet Medicare requirements. At this point, it may be too late to appeal the results of the earlier probe audits, leaving the provider in the unenviable position of defending itself when CMS thinks the results of the probe audits are set in stone.
Therefore, providers should not discount even small UPIC audits. Any claims denied by the UPIC should be timely appealed and contested through the Medicare claims appeal process. Further, a provider should carefully document all communications with the UPIC and all documentation that it submits to the UPIC, in the event that the UPIC claims it lost or did not receive documents from the provider.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare law and regulation. If you or your healthcare entity has any questions pertaining to UPIC audits or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.