Unified Program Integrity Contractor (UPIC) audits are on the rise among hospices, with some seeing penalties like reimbursement suspension or repayments.
The U.S. Centers for Medicare & Medicaid Services (CMS) contracts UPIC entities to conduct investigations and audits related to potential fraud, waste or abuse. While these audits have rooted out some bad actors, they are also a time-consuming and expensive process for hospices.
Providers should ensure they are prepared for a potential audit and try to identify ways to improve compliance beforehand, according to Husch Blackwell Attorney Bryan Nowicki.
“Given how much more active UPICs have become, … be vigilant about all the different things that they can do and more proactive in responding,” Nowicki said during a recent Husch Blackwell podcast. “For some hospices that can be crippling [and have] very serious consequences.”
If a UPIC auditor determines that fraud allegations are credible, or if they see evidence of an overpayment, they can suspend a hospice’s Medicare payments or cut them off from future reimbursement, according to Nowicki. Those funds go into a trust until their investigation is complete, though hospices can request that auditors expedite their investigation due to financial hardship.
The total cost of addressing a suspected $10,000 overpayment, for example, could be in the millions of dollars, Nowicki said on the podcast.
UPIC audits typically start with a request for documents, including claims and related materials, as well those related to a hospice’s business practices or relationships, including referral partners.
Factors that are considered red flags include missing signatures for certifying physicians, incomplete or inaccurate documentation, long lengths of stay or high rates of live discharges.
If the contractor perceives signs of wrongdoing, they may refer the case to law enforcement like the U.S. Department of Health & Human Services Office of the Inspector General (OIG) or the U.S. Department of Justice. In some cases regulators can collect or impose penalties before a hearing occurs.
Hospices can appeal findings, but have limited options when it comes to challenging payment suspension, according to Meg Pekarske, hospice attorney and partner at Husch Blackwell.
This means that a hospice’s best option is to do all they can to ensure they are in compliance and prepared to respond to regulators’ requests.
“The pivot that we’re seeing with more UPICs is all the more reason to be diligent, because they can get really rough,” said Pekarske during the podcast. “Be aggressive in defending your organization and take these things seriously. The hard part is, you have limited appeal rights related to some things like payment suspension. You can rebut that, but oftentimes this is not very successful.”
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