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Medical Review:

UPICs Should Do More, OIG Urges

Published on Wed Oct 12, 2022

Protect yourself from UPIC reviews with tips from legal experts.

Don’t be surprised to see UPICs up their volume of hospice medical review following a new HHS Office of Inspector General report.

In a review of Unified Program Integrity Contractor 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 a report released Oct. 3, 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 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

Hospices 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 released in August.

UPIC audits “tend to be the highest dollars out of all … of these types of audits,” Burns warned in the podcast about UPIC and other contractor review.

For hospices, factors such as length of stay and higher levels of care will draw heightened scrutiny, noted Burns, in Husch’s Denver office.

“Wherever the government may see an opportunity for a provider to increase revenue is where we’re going to see the activity,” explained Nowicki, in Husch’s Madison, Wisconsin office. A factor that increases reimbursement over the baseline will attract reviewer attention. Reviewers will “follow the money,” he noted.

Of course, 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.

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

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 is it going to take to get your money, it could be several years sometimes,” she cautioned.

Note: 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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