What is a Medicare UPIC?

by Keith Grunig

Headache of ADR Stress

What is a Medicare UPIC?

A UPIC is a "United Program Integrity Contractor."  That means, it is a contractor that is looking for improper payment (fraud) and the results can be devastating, even ruinous for home health and hospice agencies.  UPICs essentially identify monies that need to be recouped by the MACs.  

According to Noridian, "UPICs were created to perform program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching. Medicare Part C and D program integrity efforts are handled separately by one national contractor known as the Medicare Drug Integrity Contractor (MEDIC). The UPICs and the MEDIC work under the direction of the Center for Program Integrity (CPI) in CMS."  (Noridian Website Quote

What triggers a UPIC?

According to CMS, CMS often receives referrals of potential improper payments from MACs, UPIC, and other investigative agencies.  "UPICs primary goal is to investigate instances of suspected fraud, waste, and abuse in Medicare or Medicaid claims. They develop investigations early, and in a timely manner, take immediate action to ensure Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC (Medicare Administrative Contractor)."  

UPICs do the following:

  • Investigate potential fraud and abuse for CMS administrative action or referral to law enforcement;
  • Conduct investigations in accordance with the priorities established by CPI's Fraud Prevention System;
  • Perform medical review, as appropriate;
  • Perform data analysis in coordination with CPI's Fraud Prevention System, IDR and OnePI;
  • Identify the need for administrative actions such as payment suspensions, prepayment or auto-denial edits, revocations, postpay overpayment determination;
  • Share information (e.g. leads, vulnerabilities, concepts, approaches) with other UPICs/ZPICs to promote the goals of the program and the efficiency of operations at other contracts; and
  • Refer cases to law enforcement to consider civil or criminal prosecution.

In performing these functions, UPICs may, as appropriate:

  • Request medical records and documentation;
  • Conduct interviews with beneficiaries, complainants, or providers;
  • Conduct site verification;
  • Conduct an onsite visit;
  • Identify the need for a prepayment or auto-denial edit;
  • Institute a provider payment suspension; and
  • Refer cases to law enforcement.

UPICs are serious business and should not be taken lightly.  

What to do in case of an audit:

Elizabeth Hogue in an article called UPIC Audits: Recommendations from the Front Lines says it way better than we ever could.

Home health agencies and hospices remain targets of audits by United Program Integrity Contractors (UPICs). The results of these audits can be devastating because they may threaten the ability of providers to remain in business, especially when overpayments are extrapolated to overpayments in the millions of dollars. UPIC audits, therefore, must be taken seriously and action must be taken.
Perhaps providers’ first goal should be to get rid of UPIC audits as quickly as possible! In other words, providers should strive to satisfy UPIC reviewers so that they close their files as quickly as possible. 
In this regard, it is important for providers to understand that UPIC audits are not Additional Development Requests (ADRs). A key difference is that UPICs may extrapolate overpayment amounts that result in overpayments of millions of dollars. The amounts may be so large that providers are driven out of business.
Bearing in mind that providers should work to cause UPICs to close their files as soon as possible, it is important for providers to take a hard look at records requested by UPICs for review before they are sent to the UPICs. In other words, providers should never just send records in response to requests from UPICs without reviewing them first.
Providers should scrutinize records very carefully before they are sent for technical bases for denials. For home health providers, technical bases for denials may include deficiencies, such as the date of the face-to-face encounter is not included on the Home Health Certification and Plan of Care. An example of a frequent technical issue for hospices is certificates of terminal illness (CTIs) that are unsigned.
Home health and hospice providers should also carefully review records for more substantive deficiencies. Home health agencies should review records for documentation that establishes homebound status and that shows that skilled nursing and/or therapy services were reasonable and necessary. Hospice providers should carefully review records to determine whether patients had terminal illnesses with a prognosis of six months or less if disease processes run their normal course.    
When providers find that technical requirements have not been met and/or more substantive requirements have not been sufficiently documented, they must work hard to amend, supplement and/or correct records to meet applicable requirements before records are submitted to UPICs.
Supplements, amendments and/or corrections must, of course, be done consistent with applicable industry standards and providers’ internal policies and procedures. Providers may not, of course, backdate changes to records. Absolutely no backdating of records, ever!
After any deficiencies in documentation have been addressed as far as possible, providers are well-advised to develop summaries of records that describe how the more substantive requirements described above were met. What documentation is included in the record that shows that patients were homebound? Why were the skilled services provided reasonable and necessary consistent with documentation in the patients’ records? How did providers conclude that patients had terminal illnesses? These summaries should reference specific exhibits and exhibits referenced should be attached to summaries submitted to the UPICs.
As indicated above, the goal is to convince UPICs to close their files without requesting a second, often much larger, sample of records based upon which UPICs may extrapolate overpayments. Experience has shown that investing the time and resources to address key issues before records are submitted to the UPICs pays off.
©2022 Elizabeth E. Hogue, Esq. All rights reserved.
How Can Home Care Answers Help with audits?
In a previous post, we talk about ADRs and what to do.  You can read that here.   Up Front Accuracy from documentation to billing to chart submittal is your best defense in protecting your agency's bottom line.  If we can help on the front end, it can save a lot of headache on the back end.  Accuracy leads to compliance.   Call us today so we can help. 


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