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Medicare Compliance & Reimbursement

Audits:

Pocket These Legal Tips to Protect Yourself Against UPIC Reviews

Published on Fri Dec 02, 2022

Don’t ignore the nuances and complexities of UPIC audits.

If the possibility of a Unified Program Integrity Contractor (UPIC) review isn’t on your radar, it should be. These audits are invasive, carrying oftentimes catastrophic consequences for the provider under review — and a new HHS Office of Inspector General (OIG) report suggests investigations are on the rise.

Background: In a review of UPIC activity, the OIG found “wide unexplained disparities in program integrity activities across UPICs, even after adjusting for the size of their respective oversight responsibilities,” according to the report, “UPICs Hold Promise To Enhance Program Integrity Across Medicare and Medicaid, But Challenges Remain.”

Reminder: Currently there are three UPICs covering five regions of the U.S. — Qlarant Integrity Solutions (Western and Southwestern regions), CoventBridge (Midwestern region), and SafeGuard Services (Northeastern and Southeastern regions). The UPIC contracts “combine and integrate functions previously performed by the Zone Program Integrity Contractor (ZPIC), Program Safeguard Contractor (PSC) and Medicaid Integrity Contractor (MIC) contracts,” the Centers for Medicare & Medicaid Services (CMS) explains on its Review Contractor Directory webpage.

The OIG found that “the UPIC that opened the most investigations opened three times as many investigations as the UPIC that opened the fewest investigations for every $100 billion in spending,” the report says. “Similarly, one UPIC referred more than twice the number of cases as another UPIC and one UPIC completed more than three times the number of data analysis projects as another,” the OIG continues.

“UPICs also varied in conducting other program integrity activities such as leads screened, administrative actions recommended, claims denied, vulnerabilities identified, and the value of overpayments they referred,” the OIG reveals in the report.

But it’s not slacking contractors that are the problem, CMS Administrator Chiquita Brooks-LaSure says in the agency’s response letter to the report. It’s home health and hospice agencies’ fault. “Home Health and Hospice investigations are more complex and consume more resources than other types of investigations,” Brooks-LaSure explains in the letter. “A jurisdiction conducting more Home Health and Hospice investigations may conduct fewer investigations overall,” she says.

Plus: “The landscape of fraud varies throughout the country,” Brooks-LaSure adds.

The OIG recommends that “CMS should identify the reasons for the unexplained variation in program integrity activities across UPICs,” and Brooks-LaSure concurs. But she does note that “CMS continuously monitors the program integrity activities performed across UPICs to ensure the optimal use of program integrity resources. As part of this monitoring, we expect variations between jurisdictions and programs due to a number of factors, including the number of fraud leads received, available budget, and type of investigations.”

Beware These Overlooked Audit Pitfalls

Providers have their hands full with UPIC audits as it is, noted attorneys Meg Pekarske, Bryan Nowicki, and Erin Burns with law firm Husch Blackwell in a recent podcast. UPIC audits, as well as those from other review contractors, “can be an administrative burden and really need to be taken seriously,” Pekarske urged in the podcast.

Important: UPICs are allowed to analyze your claims data and can initiate an audit for a variety of reasons, says law firm Wachler & Associates, P.C. in a blog post. “This means that providers with unusual billing patterns or high utilization are inherently more susceptible to UPIC investigations, even if these billing practices are for entirely legitimate reasons, such as a particular patient population,” Wachler warns.

That’s where detailed notes come into play. Documentation is key to passing an audit, Burns emphasized. “Your documentation is what’s going to make or break your audits,” she said in the podcast.

And your documentation won’t do you much good if reviewers can’t access it. The first time you print out a medical record shouldn’t be when you get a record request, emphasized Pekarske, also in Husch’s Madison office. “You need to see how your record produces,” she urged. “There can be things that look funky that might be misinterpreted that you’re not even aware of,” because the record looks different on screen versus on paper, she noted. That can lead to many problems, including denials.

But factors other than documentation are important too. For example, reviewers have asked for agencies’ electronic signature policies. “If you don’t have one, you may consider that,” Burns advised.

Providers also must have written policies that back up their operating procedures, Burns added.

Small probe audits are another problem that practices shouldn’t push to the side or underestimate, the Wachler blog says. “These small probe audits may at first appear to be not worth defending or appealing. However, UPICs often use the results of these small probe audits to jump to the conclusion that the provider is committing fraud and, seemingly out of nowhere, suspend the provider’s Medicare payments,” Wachler reminds.

And finally: If you receive a UPIC or any other review notice, don’t expect a quick resolution, Nowicki suggested. “Be prepared for this to be a long process,” he counseled.

“It is a slog,” even with appeals processing faster than before, Pekarske agreed. “In terms of how long it is going to take to get your money, it could be several years sometimes,” she cautioned.

Resources: The 42-page OIG report, which also focuses on UPICs’ lackluster Medicaid review rates, is at https://oig.hhs. gov/oei/reports/ OEI-03-20-00330.pdf. Listen to the Husch Blackwell podcast at https://hospicelawinsights.simplecast. com. Find your UPIC with a state-by-state map at www.cms. gov/research-statistics-data-and-systems/monitoring-programs/ medicare-ffs-compliance-programs/ review-contractor-directory-interactive-map.

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