Unified Program Integrity Contractor (UPIC) - JE Part A

UPICs were created to perform program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching. Medicare Part C and D program integrity efforts are handled separately by one national contractor known as the Medicare Drug Integrity Contractor (MEDIC). The UPICs and the MEDIC work under the direction of the Center for Program Integrity (CPI) in CMS.

• UPIC Functions
• Non-UPIC Functions

UPIC Functions

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). Actions the UPICs take to detect and deter fraud, waste, and abuse in the Medicare program include:

• 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 also support victims of Medicare identity theft. A provider or supplier who believes he/she may have had their provider information stolen and used to submit Medicare claims for which payment was made can request their UPIC to investigate the case. The UPIC will then work with CMS to determine the appropriate remedial action to assist the provider. See the CMS Victimized Provider Project for guidance on how to avoid and report Medicare identity theft and information on current scams.

Non-UPIC Functions

The following are some of the major functions the UPICs do not perform. These functions are performed by the MAC (Noridian):

• Claims processing, including paying providers/suppliers;
• Claim payment determination;
• Claims pricing;
• Provider outreach and education;
• Medical review not for benefit integrity purposes;
• Recouping monies lost to the Trust Fund (the UPICs identify these situations and refer to the MACs for recoupment);
• Complaint screening;
• Appeals of UPIC decisions.