CMS Wants to Run Fraud Investigations Itself. What It Means for UPIC Audits

UPIC audits look headed for a change. On Oct. 5, the Centers for Medicare & Medicaid Services (CMS) published a request for information asking 28 questions about whether the agency should direct Medicare fraud investigations itself. Under the model it describes, CMS would run the data analysis, pick the leads and vet them with law enforcement. Unified Program Integrity Contractors (UPICs) would then work the cases CMS assigns, and any lead a contractor finds on its own would go back to CMS for review before an investigation opens. Comments on the RFI are due today, Nov. 4.

Home health and hospice groups are cautiously hopeful. Katie Wehri of the National Alliance for Care at Home told McKnight's Home Care that CMS picking cases from its own data analysis would bring more consistency across reviewers. She also flagged a risk. A bigger CMS role in enforcement means new bottlenecks and slower answers for providers. LeadingAge pointed to the overlapping audits many hospices already juggle and said better coordination would cut duplicate requests. Attorney William Dombi was more guarded. The old complaints about UPICs, such as how they apply coverage policy, how they choose whom to audit and when they extrapolate from a sample, don't disappear because CMS holds the steering wheel.

What UPIC audits and centralized fraud enforcement mean for compliant agencies

Read the RFI next to everything else this fall and the direction is plain. CMS wants to spot problems in the data early instead of chasing them years later. The pending CRUSH rule points the same way, and so does the move to extend the Review Choice Demonstration to California. At a FUTURE panel covered by Home Health Care News, Wehri said enforcement now reaches providers without a finding of fraud. Gayle Devin of Home Care Delivered put the worry simply. "Do we make mistakes? We do. But there's a difference between a mistake and patterns."

So how do you show you're on the right side of that line? Start with your own outliers. If your visit counts, lengths of stay or admission sources look unusual next to peers, write down why before anyone asks, whether you serve a rural area or a high-acuity population. Run an internal audit with no warning, the way Freedom Senior Services plans to. Pull five charts and check that orders, visit notes and billed visits line up by date. And make sure your enrollment and ownership records match what CMS has on file.

Most of those checks come back to one question, which is whether the visits on the claim happened the way the schedule says. CareSync® keeps planned and completed visits side by side, so the office finds that answer without digging through three systems. Whatever CMS decides after today's comment deadline, an agency with clean visit records and a written explanation for its outliers will be in a better spot than one scrambling after the letter arrives.