CMS established the UPICs to consolidate program integrity activities formally performed by the Zone Program Integrity Contractors (ZPICs), Program Safeguard Contractors (PSCs), and Medicaid Integrity Contractors. As a result, UPICs are the only program integrity contractors that monitor both the Medicare fee-for-service (FFS) and Medicaid programs. UPICs are responsible for identifying and protecting against fraud, waste, and abuse using both pre-payment medical reviews and post-payment audits. UPIC audits should be taken very seriously as they can result in high-dollar extrapolated overpayment demands, payment suspensions, and referral to law enforcement for additional review.
What triggers a UPIC audit?
- According to CMS, CMS often receives referrals of improper payments from MACs, UPICs 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 not to be recouped by the Medicare Administrative Contractor.
UPICs do the following:
- Investigate potential fraud and abuse of 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, post-pay overpayment determination
- Share information (e.g. leads, vulnerabilities, concepts, approaches) with other UPICs/ZIPCs to promote the goals of the program and the efficiency of operations at other contracts
- 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
- Refer cases to Law Enforcement
Be aware! UPIC Audits are not a free pass.
This is my opinion.
Michael G. Warshaw, DPM, CPC
THE 2026 PODIATRY CODING MANUAL IS NOW AVAILABLE in either Book or Flash-drive formats. It has been completely updated for the calendar year 2026. Many offices across the country consider this to be their “Bible” when it comes to coding, billing, and documentation. The price is still only 125.00 including shipping! To
purchase, access the website drmikethecoder.com.
No credit card? No problem! Just send a check for 125.00 to the following address:
Dr. Michael G. Warshaw
2027 Bayside Avenue
Mount Dora, Florida 32757
Read Comments