If it is determined that an update to the FFR is necessary, CMS and the UPIC shall collaborate to draft an FFR Addendum, along with the FFR Addendum State Transmittal Letter (Appendix H), which CMS shall submit to the SMA upon completion. While some health care providers might think they have no choice but to accept an auditor's findings, the attorneys at Baker Donelson have years of experience vigorously representing and defending the interests of our clients. UPIC audits are performed when the investigator suspects fraud, waste or abuse in Medicare or Medicaid claims. the UPIC shall notify CMS of the discrepancies and discuss a proposed resolution. For example, a contractor could review 30 claims, assess an error rate, and then apply that error rate to a universe of claims encompassing several years of payments to a provider.įor small providers in particular, an audit can mean a potential death sentence. Of greatest concern to health care providers, some auditors use their authority to sample a small number of claims to extrapolate their findings to a wider universe. And all auditors have an incentive to find problems – especially RACs, who receive a portion of what they recover. While each type of auditor operates somewhat differently and serves a different function, all share a common goal: Recapture payments made to health care providers months and years earlier. Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPIC), Comprehensive Error Rate Testing (CERT), Medicare Administrative Contractors (MACs) and the Department of Health and Human Services Office of Inspector General (HHS OIG) all have jurisdiction to review the practices of providers participating in the Medicare program. Now, more than ever in Medicare’s history, it literally pays to follow the rules.Įstablished in 1996 as part of the Health Information Portability and Accountability Act (HIPAA), and reinforced by legislation such as the Medicare Modernization Act of 2003 (MMA), the Medicare Integrity Program (MIP) has given rise to contractors to conduct medical, utilization and fraud review. CMS requires UPICs to track all costs incurred and bill them to the correct program’s funding source (i.e., Medicare, Medicaid, or Medi-Medi). /audits across Medicare and Medicaid, and assure that CMS’s national priorities for both Medicare and Medicaid are executed and supported at the state level or within the UPIC jurisdiction. ![]() The HMEB Podcast examines essential news, trends, and developments and interviews industry experts to find out how HME provider owners and operators can run efficient, profitable, and growing businesses with an eye on patient care.Under the guise of "program integrity" – eliminating errors and fraud and, more broadly, protecting the Medicare Trust Fund – the federal government has in the past two decades unleashed a small army of auditors, mostly independent contractors, to analyze medical records and search for overpayments, whether the result of human error or intentional deception. What is a Medicare UPIC A UPIC is a 'United Program Integrity Contractor.' That means, it is a contractor that is looking for improper payment (fraud) and the results can be devastating, even ruinous for home health and hospice agencies. Each UPIC submits a Basis of Estimate to CMS that reflects how the UPIC anticipates allocating its resources, time, and workload across Medicare, Medicaid, and Medi-Medi activities. ![]() In the previous episode of the HMEB Podcast, Gary Sheehan, MBA, CEO of Spiro Health, who has shared his insights and perspectives on how COVID-19 has impacted providers during the pandemic, rejoins the podcast to discuss how sleep providers and the entire HME industry can transition into a post-pandemic reality and what that might look like. Current episode of the HMEB Podcast, audit expert Wayne van Halem, president of The van Halem Group, joins the podcast to discuss how CMS’s resumption of TPE, RAC and other audits programs is progressing, as well as what expanding resources at OMHA might mean or HME providers.ĭownload the episode on iTunes, Stitcher, Google Podcasts, or listen to it here:
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