Unified Program Integrity Contractors (UPIC) Audits

UPIC stands for Unified Program Integrity Contractors. Created by the Centers for Medicare and Medicaid Services (CMS), UPIC audits are used to identify and remedy fraud in Medicare and Medicaid. UPICs have nearly replaced ZPICs (Zone Program Integrity Contractors) as the primary mechanism for CMS to pursue fraud and abuse audits. There are currently five UPIC jurisdictions that monitor the entire country, with each zone comprising anywhere from seven (7) to twelve (12) states. They also audit United States territories such as Puerto Rico, Guam, the Virgin Island, American Samoa, and the Northern Marianas Islands. The zones are aligned with each state or territory’s Medicare Administrative Contractors (MAC) zone.

Who is at Risk for UPIC Audit?

While some think UPIC audit selection is arbitrary, it’s usually based on two things: consumer complaints or data analysis. Consumer complaints usually come from employees or their beneficiaries. Data Analysis, however, will uncover: patients with extended home healthcare visits, patients with long stays in hospice care, or acute care facilities with either a large number of cases or an unusual mix of cases.