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Health Integrity - UPIC Auditor

UPIC AUDITS - THE DETAILS


At Jackson Davis, our core business is helping providers build winning RAC, TPE & UPIC audit defense strategies and win Medicare & Medicaid appeals cases.  We've been providing CMS compliance services for over 25 years.  We are passionate about what we do and wholly dedicated to our client's success.  We have worked with 100s of healthcare providers nationwide and assisted with 10,000+ Medicare and Medicaid appeals.

Contact us today at (303) 586-5003
Email us at support@upicaudits.com

UPIC AUDITS - PROGRAM SUMMARY

CMS awarded the UPIC Jurisdiction 1 task order to NCI AdvanceMed for services that encompass Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky, Iowa, Missouri, Nebraska and Kansas.

CMS awarded the UPIC Jurisdiction 2 task order to 
Health Integrity for services that encompass North Dakota, South Dakota, Wyoming, Idaho, Montana, Washington, Oregon, California, Nevada, Utah and Arizona. *[award is being challenged]*

CMS awarded the UPIC Jurisdiction 4 task order to SafeGuard Services for services that encompass West Virginia, Virginia, Tennessee, North Carolina, South Carolina, Georgia, Alabama and Florida.

CMS awarded the UPIC Jurisdiction 5 task order to 
SafeGuard Services for services that encompass Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania, Washington D.C., Delaware and Maryland.

In mid-2016, the Centers for Medicare and Medicaid Services (CMS) initially awarded "umbrella" or high-level "IDIQ" UPIC audit contracts to 7 separate companies.  These IDIQ audit contracts each covered a possible 10-year span and up to $2.5 billion in payments for their services.  The agency announced its selections of the contractors in a series of May, 2016 posts to FedBizOpps.  Awardees include:

NCI AdvanceMed
Health Integrity LLC
HMS Federal
Noridian Healthcare Solutions
Safeguard Services LLC
StrategicHealthSolutions LLC
TriCenturion

Subsequent to the initial IDIQ awards, CMS has awarded delivery task orders for services across 4 of 5 geographic areas with multiple states:

CMS One PI - UPIC Audits and UPIC Appeals
NCI AdvanceMed - UPIC Auditor
SafeGuard Services - UPIC Auditor

​​​In FY 2015, the Centers for Medicare and Medicaid Services (CMS) initiated plans for implementation of the Unified Program Integrity Contractor (UPIC) initiative. This initiative was consistent with the CMS agency-wide strategic plan for program integrity and was designed to consolidate / integrate a full range of audit, detection and enforcement activities.


The Center for Program Integrity (CPI), as part of CMS, is tasked with implementing strategies that CMS believes will reduce fraud, waste, abuse and other overpayments.  The concept of a unified program integrity strategy involves third-party audit contractors performing work across the Medicare and Medicaid program integrity continuum (i.e. SafeGuard Services, NCI Advancemed, etc.). ​The Unified Program Integrity Contractors (UPICs) perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States.  Specifically, the UPIC’s perform integrity related activities associated with Medicare Parts A, B, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), Medicaid, and the Medicare-Medicaid data match program (Medi-Medi).  The UPIC contracts operate in five (5) separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the Zone Program Integrity Contractor (ZPIC), Program Safeguard Contractor (PSC) and Medicaid Integrity Contractor (MIC) contracts.


According to CMS, this unified program integrity strategy is designed to build upon the improvements that CPI has made over the past several years in multiple arenas.  CMS also anticipates that this approach will lay the groundwork for (1) greater CMS compliance by providers; and (2) the fostering of further program integrity coordination with other private and governmental payers across the entire health care industry:


(1) Break down the boundaries between Medicare and Medicaid program integrity activities to create a truly holistic and coordinated Medicare / Medicaid program integrity strategy using UPIC audits;


(2) Create a more unified, coordinated nationwide program integrity strategic framework enabling the CMS to set national goals and priorities to ensure that local or regional program integrity activities are consistent with the CPI’s national-level strategy, while still allowing for some regional variation in program integrity activities to respond to local or regional trends in waste, fraud, and abuse;


(3) Further enable cooperation and communication between the various regional program integrity audit contractors to ensure a truly national approach to providers or CMS compliance trends that cut across regions;


(4) Strengthen the CMS’s national-level direction of the Contractors’ work by ensuring a rapid, accurate flow of information to the CMS about all levels of the UPIC audit contractors’ workload and activities, UPIC appeals outcomes and CMS compliance high-risk areas; and


(5) Ensure that the CPI’s new and emerging centralized fraud detection mechanisms and other tools, for example the Fraud Prevention System predictive analytics tool (“FPS”) and the Health Care Fraud Prevention Partnership (“HFPP”), are fully and consistently leveraged across the entire nation.​​

[The One PI System houses claims data, provider-specific information, core business logic and data analytics that drive RAC audits, TPE audits & UPIC audits [click here for example].  According to CMS,  The One PI vision is "to provide a secure, centralized environment containing current, consistent, and integrated Medicare and Medicaid health benefits data, analyzed with standard tools, to detect fraud, waste, and abuse and protect health care expenditures."] 

Moving forward, CMS is developing a Unified Program Integrity Contractor (UPIC audits) strategy that restructures and consolidates the current Medicare and Medicaid program integrity audit and investigation work.  UPIC audit contractors will also coordinate activities with CMS and other agencies at the federal, state and local government levels; as well as other CMS partners and contractors.

By consolidating a wide range of audit & enforcement efforts, CMS believes the UPIC initiative will provide benefits to aggressively pursuing fraud, waste, and abuse.  In addition, CMS sees benefits to the UPIC strategy that include reduced state and provider administration, increased audit contractor accountability, reduced overhead and administrative costs, enhanced data / reporting and improved program oversight.  The UPIC audit initiative is considered by CMS to be the next logical step in the transition to a wholly integrated program integrity strategy.

Call Today!  (303) 586-5003  support@upicaudits.com 

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