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UPIC Audits on the Rise

Healthcare providers have seen a disturbing rise in audits by Medicare Unified Program Integrity Contractors (UPICs). The stated purpose for the UPICs is to investigate instances of suspected fraud, waste, and abuse in Medicare or Medicaid claims. However, UPICs are often over-zealous in alleging fraud where there is none, thereby causing devastating consequences for Medicare providers.

Like the Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), and the now-defunct Zone Program Integrity Contractors (ZPICs), UPICs are government contractors that have been tasked by the Centers for Medicare & Medicaid Services (CMS) to review claims submitted by Medicare providers and identify alleged overpayment to providers. Currently, the companies that hold contracts to act as UPICs are CoventBridge Inc., Qlarant Integrity Solutions, LLC, and SafeGuard Services.  However, UPIC investigations are different from other types of Medicare audits because the UPICs are meant to specifically seek out fraud and a UPIC investigation is more likely to lead to collateral consequences, such as a suspension of Medicare payments or a revocation of Medicare billing privileges.

A UPIC investigation often follows the same trajectory. First, the UPIC will conduct a series of probe audits of the provider. These may seem inconsequential because they involve only a few claims or a small dollar value at issue. Second, the UPIC will deny nearly every claim it reviews and indicate that it has found a “credible allegation of fraud.” Third, the UPIC will lead CMS to suspend the provider’s Medicare payments. Around the same time as the Notice of Suspension, the UPIC will request additional medical records, usually for significantly more claims than before. Fourth, and usually several months later, the UPIC will issue another set of audit findings. This final audit will often include a statistical extrapolation and demand a significant repayment, often in the hundreds of thousands or millions of dollars. In some cases, the UPIC can also lead CMS to revoke the provider’s Medicare billing privileges.

Often the UPICs are over-eager to allege that the provider has committed fraud, generally because the UPIC mis-reads the provider’s records, does not understand certain clinical terms, applies the wrong coverage criteria, or even simply loses the records the provider submitted and claims to have never received records. Once a UPIC has alleged fraud, however baseless, it can lead to further audits and investigations and can lead CMS to take action against the provider, including suspension, revocation, and placement on the CMS Preclusion List.

Each decision by the UPIC can be appealed, including the claims denied in the audits and any suspension or revocation. Medicare providers should not discount even seemingly small UPIC audits because they indicate that the provider has been targeted by the UPIC and the UPIC is likely to continue and use the results of the initial probe audits to justify later actions. A UPIC investigation is not simply another audit to respond to and appeal, but is often a lengthy ordeal that requires a multi-facet appeal and advocacy strategy to endure.

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


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