How do I handle a UPIC Audit?

by Ed Dieringer, PT

Regulatory Stress in Healthcare


How do I handle a UPIC?


CMS UPIC Audits: Is Your Home Health Agency Prepared for a Successful Defense?


How do I appeal a UPIC Audit?

 Medicare Certified Home Health Agencies (HHA) are experiencing unacceptably high denial rates from Unified Program Integrity Contractors (UPIC).  Most of the UPIC  reasons for denial start with invalidating the home health certification process. This article will discuss a common example I see in my chart review and appeal preparation in which UPICs seek to impose erroneous standards not supported in the Medicare Benefits Policy Manual, Publication 100-2, Chapter 7 (MBPM) and home health laws found in 42 CFR (42CFR) to deny the Physician’s or NPP’s Face to Face Encounter (FTF) Narrative.  In this approach, the UPIC attempts to invalidate the whole of the medical record without producing any evidence to support its claim denials.   


For example, one UPIC repeatedly states: The documentation received did not support that the beneficiary was eligible to receive services under the Medicare home health benefit because the face to face encounter documentation did not:

  • “corroborate the need for home health services
  • specify the need for home health care
  • specify the need for in-home SN, PT, OT
  • specify the patient’s homebound status
  • make changes to the beneficiary’s treatment plan related to the primary diagnosis.”


In reality, MBPM clearly states:

“The certifying physician or allowed practitioner’s… medical recordfor the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s: Need for the skilled services and Homebound status.”  [Emphasis added.]


One can readily see the specific regulatory wording for what is considered a valid certification for home health services does not rest solely on the FTF narrative.  Rather, the start of care “medical record,” which contains the FTF narrative, other narratives of prior relevant medical services and diagnoses, OASIS data set and comprehensive assessment, physician/NPP orders, and plans care, all “tell the story” of the patient’s “overall condition” that “justifies” and “substantiates” the “need for skilled services and homebound status.”  In other words, the UPIC’s attempt to deny services by isolating the FTF narrative from the context to the whole of the start of care medical record is contradicted by the MBPM and 42CFR regarding certification requirements. 


Further, since the MBPM and 42CFR do not state the FTF narrative must “specify the need for home health care, in-home SN, PT, OT, and homebound status,” or that there must be “changes to the beneficiary’s treatment plan related to the primary diagnosis,” the UPIC cannot legally impose its own requirements concerning such.  In other words, it is not necessary, or practical, to make these expected additional statements in the FTF narrative when the whole of the FTF and medical record clearly indicate these needs exist and “corroborate the need for home health (skilled) services.” 


The Bottom Line: A UPICs’ primary purpose is to identify fraud, waste, and abuse of CMS funds.  A UPIC audit indicates your home health agency claims are already suspect.  It is not surprising then that a UPIC audit is biased to confirm its suspicions.  As seen by the quotes in this article, the UPIC has a strong propensity to justify its denial of your patients’ clearly medically necessary and reasonable Medicare home health services based on the misinterpretation and/or misapplication of the home health certification requirements.  The low hanging fruit is the FTF narrative because the UPIC must go no further through hundreds of pages per medical chart to deny the claim.  


The consequences of a home health agency not vigorously and effectively appealing these unreasonable denials can be devastating.  The UPIC’s audit results can lead to broader and deeper audits that add significant administrative work and potential for consequential legal and/or financial actions by CMS against your Home Health Agency. Therefore, from the moment your agency receives the UPIC’s audit request through the Office of Medicare Hearings and Appeals process, it is vital to dedicate staff to fully understand and focus on what is required for compliance with the audit. This staff must carefully review and organize all medical records being submitted in a readable and understandable order.  They must also ensure that ALL record details are included and tell the story of WHY skilled services were necessary.   For a refresher on OASIS documentation, click here


Yes, it is a long a costly process to process to fight these UPIC claim denials, but those agencies, well-armed with the actual words of applicable laws and CMS policies, can prevail in their defense.  Homecare Answers’ can help your agency staff be successful through this arduous process of navigating the technicalities through direct intervention, or consulting services.  Homecare Answers also provides OASIS compliance, coding, and chart review to help assure proper billing that is supported by the medical record.  And this is done at a rate cheaper than a team of attorneys. 

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.  

Ed Dieringer, PT, is a revenue cycle consultant specializing in ADR review and payer appeals to help HHAs defend against the unsupported denial of insurance claims.  His work has resulted in the successful appeal and reversal of numerous denials and UPIC audits for mulitple home health agencies across the nation.  As a former Home Health Agency owner, he knows and understands the complexity of the industry but has the knowledge and skills to help agencies of all sizes navigate the difficult regulatory environment.  

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