CMS UPIC Audits: Know Your Risk

 

 

Medicare and Medicaid providers, beware: you could be at risk for a Unified Program Integrity Contractor (UPIC) audit and not even know it.

A UPIC audit is serious, and they aren’t random. Knowing your risk is the first step toward protecting your practice, reputation, and patient care.

What is a CMS UPIC audit?

UPICs are not like your regular auditors. They are contractors—private companies that CMS hires to detect and investigate potential fraud, waste, and abuse (FWA) happening in the Medicare and Medicaid programs.

UPIC auditors conduct targeted post-payment audits to identify improper billing and documentation practices, a hallmark of FWA. Guilt is often assumed, and it’s up to the provider to prove their innocence. Having the right documentation and adjudication support helps.

Who is at risk for a UPIC audit?

Any provider or supplier billing Medicare or Medicaid is subject to—and, thus, should be prepared for—a UPIC audit. Some providers are more at risk than others:

  1. Specialized providers like home health, hospice, behavioral health, and managed care providers: These settings often involve complex care journeys and documentation, which are more likely to raise red flags.
  2. Medicare and Medicaid suppliers like home medical equipment (HME) and durable medical equipment (DME) providers.
  3. High-dollar claims or complex cases involving multiple specialties, care settings, or encounters. These cases will be more likely to be flagged in UPIC’s data aggregation and analysis pre-audit.
  4. For-profit and private equity-backed healthcare organizations: CMS is piloting a program developed to spot FWA in healthcare organizations acquired by private equity-backed companies. An ownership change could trigger the UPIC to complete a full chart review audit.
  5. Providers practicing in Florida, Texas, Ohio, and Michigan—these are UPIC audit hotspots.

Are you audit ready?

The best defense against a UPIC audit is preparation. Protect your business by:

  • Reviewing your billing and documentation practices regularly.
  • Training staff on compliance protocols.
  • Partnering with a team who understands the UPIC audit and appeals processes.

Get UPIC audit ready

Help your team understand more about UPIC audits.