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Unified Program Integrity Contractors (UPICs)

Published on 

Tuesday, July 7, 2020

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In June, CMS issued Transmittal 10184 (Change Request (CR) 11812), providing information about updates being made to the Medicare Program Integrity Manual. Specifically, the Unified Program Integrity Contractors (UPICs) were inserted in several placed in this document. Transmittal specifics will be reviewed later in this article. However, as the UPICs are a recent addition to the acronym soup of Medicare Contractors (i.e., MAC, RAC, CERT, SMRC), I first want to provide you with background information about the UPIC Contractors.

What are the UPICs?

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 the following:

  • Medicare Part A,
  • Medicare Part 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.

Who Are The UPIC Contractors?

Western Jurisdiction
UPIC Contractor: Qlarant

  • Western States: Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming
  • Link to website: https://www.qlarant.com

 

Southwestern Jurisdiction
UPIC Contractor: Qlarant

  • Southwestern States: Colorado, New Mexico, Oklahoma, Texas, Arkansas, Louisiana, and Mississippi
  • Link to website: https://www.qlarant.com

 

Mid-Western Jurisdiction
UPIC Contractor: CoventBridge Group

 

Northeastern Jurisdiction
UPIC Contractor: SafeGuard Services LLC (SGS)

  • Northeastern States: Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New Your, Pennsylvania, New Jersey, Delaware, Maryland, and District of Columbia
  • Link to website: http://www.safeguard-servicesllc.com

 

South-Eastern Jurisdiction
UPIC Contractor: SafeGuard Services LLC (SGS)

 

UPICs in Action

A June 25, 2019 CMS Blog titled Medicaid Program Integrity: A Shared and Urgent Responsibility highlighted the growth of the Medicaid program from $456 billion in 2013 to an estimated $576 billion in 2016 and with this “growth comes a commensurate and urgent responsibility by CMS on behalf of the American taxpayers to ensure sound stewardship and oversight of our program resources.”

The UPICs were cited in this blog for engaging in the following activity related to Education, Technical Assistance and Collaboration:

  • CMS conducts State Program Integrity Reviews to assess the effectiveness of the state's program integrity efforts, including its compliance with federal statutory and regulatory requirements. The reviews also assist in identifying effective state program integrity activities and sharing best practices with other states. As a result of the opioid desk reviews, several states have acknowledged the need to increase their opioid-related audit activity and have engaged with the Unified Program Integrity Contractors (UPICs) to develop projects to address this weakness.

Another example of UPICs in Action is the CMS Victimized Provider Project. This program attempts to validate and remediate a provider’s claims as an identity theft victim. CMS advised providers to do the following if they think their identity has been stolen:

  • Contact your UPIC who is the CMS fraud contractor that handles investigations on behalf of Medicare.
  • Respond to any inquiry from your UPIC as part of a UPICs investigation is to interview the provider.
  • Report any suspected ID theft to the police.

 

UPIC Actions Shared in the Unified Case Management System

CMS Transmittal 871 was released on March 29, 2019. The purpose of this Change Request (CR 11159) was to add Section 4.12 to Chapter 4 in the Medicare Program Integrity Manual. This new section provides instructions related to the UPIC workload entry and update requirements in the Unified Case Management System (UCM).

The purpose for me sharing this older transmittal with you is to make you aware of how many other Medicare Contractors can and probably are following the efforts of the UPICs. This is important because here at MMP we have found that review target efforts are often duplicated by more than one type of Medicare Contractor (i.e. MACs may select a review target based on SMRC findings).

Section 4.12 indicates that “the Unified Case Management (UCM) System is a national database that the UPICs use to enter and update Medicare and Medicaid fraud, waste, and abuse data analysis projects, leads, and investigations initiated by the UPIC. Additionally, the UCM allows the UPICs to enter and track various administrative actions (i.e., pre or post-payment reviews, payment suspensions, revocations, etc.), requests for assistance (RFAs), and requests for information (RFIs) that are fulfilled by UPICs at the request of law enforcement, CMS, or other stakeholders….The following agencies/organizations currently have access to the UCM:

  • UPICs
  • National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)
  • Railroad Retirement Board (RRB)
  • CMS contractors (FPS, PIMAS, Acumen, IBM)
  • MAC Medical Review Units associated with MPIP
  • CMS
  • FBI
  • DOJ
  • HHS/OIG
  • Other federal and state partners seeking to address program integrity concerns in judicial or state health care programs

All workload received and/or initiated by the UPIC shall be saved in the UCM and shall contain identifying information on the potential subject(s) of a project, lead, investigation, etc., as well as general information on activities performed by the UPIC to substantiate the allegation of potential fraud, waste, or abuse. Investigative workload initiated by the UPIC shall contain a summary of the pertinent information related to any activities and/or resolution, and all fields in the UCM shall be updated with the applicable information as it is received by the UPIC.”

 

CMS Transmittal 10184: Medicare Program Integrity Manual (PIM) Chapter 6 Updates

Now, back to the CMS Transmittal 10184 issued on June 19, 2020. The purpose of this Change Request (CR 11812) is to update various sections within Chapter 4, 6, and 8 in the Medicare Program Integrity Manual. Today I want to call your attention to the updates in Chapter 6 – Medicare Contractor Medical Review Guidelines for Specific Services.

Prior to this CR, the following sections in chapter 6:

  • 2 - Medical Review of Home Health Services,
  • 5.2 - Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions,
  • 7 - Medical Review of Inpatient Rehabilitation Facility (IRF) Services, and
  • 7.1 - Reviewing for Intensive Level of Rehabilitation Therapy Services Requirements)

Applied to the following CMS Contractors:

  • Medicare Administrative Contractors (MACs),
  • Supplemental Medical Review Contractor (SMRC),
  • Recovery Audit Contractors (RACs), and the
  • Comprehensive Error Rate Testing (CERT) Contractor.

Effective July 21, 2020, UPICs have been added to the applicable Contractors in each of these sections.

Additionally, the Zone Program Integrity Contractor (ZPIC) has been removed from sections 6.5.6 (Length of Stay Reviews), 6.5.9 (Circumvention of PPS), and 6.6 (Referrals to the Quality Improvement Organization (QIO)) and replaced by the UPIC as to the Contractor a referral would be made to.

 

UPICs and RACs

The following note can be found on the CMS Approved RAC Topics webpage:

“CMS often receives referrals of potential improper payments from the MACs, UPICs, and Federal investigative agencies (e.g., OIG, DOJ). At CMS discretion, CMS may require the RAC to review claims, based on these referrals. These CMS-Required RAC reviews are conducted outside of the established ADR limits.”

 

UPICs and the OIG

The OIG added the Item Results of UPICs’ Benefit Integrity Activities to their Work Plan in June 2020 indicating that “the Unified Program Integrity Contractors (UPICs) are the only benefit integrity contractors that safeguard both the Medicare and Medicaid programs from fraud, waste, and abuse. The Medicare and Medicaid programs provide health coverage to more than 100 million Americans. UPICs must effectively detect and deter fraud, waste, and abuse. This study will continue OIG's work examining the results from benefit integrity contractors' identification and investigation of fraud, waste, and abuse. It also will identify any barriers and challenges UPICs have experienced while conducting unified benefit integrity activities across Medicare and Medicaid.”

It remains to be seen how involved in medical review of inpatient hospital claims for Part A payment the UPICs may become. For now, it’s important to simply be aware of the UPICs in case they do send your hospital a medical record request.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.