![]() ![]() 42 CFR 405.371(a)(1) affords contractors the authority to implement a payment suspension when the contractor “…possesses reliable information that an overpayment exists or that payments to be made may not be correct.” Essentially, in a situation where they believe claims should be denied, they can utilize this tool to stop payments to suppliers for 180 days while the conduct an audit and calculate an overpayment. You will also likely see a request for documentation at the same time on a sample of claims to which you must respond.Ī payment suspension is a tool that the UPICs are using more often these days. They may contact or visit your patients and interview them about the services they received and their interaction with you as the supplier. This could be in the form of extrapolated overpayments, claim denials, or even more significant actions including payment suspensions.Īs part of their process, UPICs will often contact your referral sources directly and request documentation. The original UPIC contracts were valued between $76 and $129 million over a multi-year contract, which means in order to show CMS a return on its significant investment, the UPICs must identify a significant amount of cost-savings to the Medicare Program. ![]() Unfortunately, what we often see are auditors identifying claim errors and overpayments versus identifying actual fraudulent activity. These audit contractors are tasked with identifying and preventing fraud, waste and abuse. Unified Program Integrity Contractors – An Overviewīy Wayne van Halem, founder and President of the van Halem GroupĪtlanta, GA - Unified Program Integrity Contractors (UPICs) have been around now since 2016.
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