How to Prepare for a CMS UPIC Audit

🛑 Important: You may be triggered for a UPIC audit and not even know it.

How does a CMS UPIC audit work?

 

A UPIC audit is a high-stakes investigation conducted by CMS contractors who are looking for fraud, waste, and abuse (FWA) in post-payment Medicare and Medicaid claims.

UPIC audits follow a multi-phase process:

  • Pre-audit screening: Your organization is screened for FWA anomalies.
  • Formal investigation: If fraud is suspected, you’ll receive official notice and documentation requests.
  • Five-level appeals process. Appeals can take years, and many providers lose revenue before a resolution is reaches.

What triggers a UPIC audit?

UPIC audits begin with a covert pre-audit phase, during which data is quietly reviewed for signs of Medicaid and Medicare FWA. UPIC auditors use advanced data analytics to flag “suspicious” billing activity.

Common audit triggers include:

    • Billing anomalies.
    • Ownership changes.
    • Risky billing patterns.
    • Whistleblower reports.
    • Random compliance checks.

👉 Know your risk: Download our UPIC Audit Risk Guide.

You’ve received a UPIC audit notification. What do you do next?

Here’s what to do when you’ve been notified:

✅ Understand the scope: Carefully review the audit notice to understand what’s being investigated.

✅ Gather documentation: Collect all relevant patient records, billing files, and documentation, ensuring they are complete, signed, and error-free.

✅ Review your compliance history: Flag any past claims or workflows that could cause concern.

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How can you prepare for a UPIC audit?

The best time to prepare is before the audit begins. A proactive UPIC audit compliance strategy can reduce your risk and improve your ability to respond.

And how you respond matters. If triggered:

✅ Assign points of contact to manage audit communication.

✅ Track every document and exchange for future appeals.

✅ Engage legal and compliance experts early.

Use this audit readiness checklist to evaluate your overall UPIC audit preparedness and UPIC audit compliance.

Know Your UPIC Audit Risk

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UPIC Audit Readiness Checklist

Are you prepared for a CMS UPIC audit? Use this checklist to evaluate your preparedness.

✅ Do you have and regularly train staff on standard documentation practices?

✅ How accurate is your billing and coding?

✅ How accurate and integrated are the billing practices of your vendors and referral partners?

✅ Are your clinical notes complete—every time?

✅ Is your documentation signed? Does this happen in a timely manner?

✅ Does your documentation defend your clinical decisions?

✅ How often do you review and update your compliance policies?

 

Protect your practice

Make sure your team is ready to respond.