Last Modified: 9/26/2019
Location: FL, PR, USVI
Business: Part A, Part B
The unified program integrity contractors (UPICs) perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States. Specifically, the UPICs perform integrity related activities associated with Medicare Parts A, B, durable medical equipment (DME), home health and hospice (HH+H), Medicaid, and the Medicare-Medicaid data match program (Medi-Medi). The UPIC contracts operate in five separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the zone program integrity contractor (ZPIC), program safeguard contractor (PSC) and Medicaid integrity contractor (MIC) contracts.
The Centers for Medicare & Medicaid Services (CMS) awarded a contract to SafeGuard Services LLC (SGS) to operate as the UPIC for the southeastern jurisdiction effective June 1, 2018.
The UPIC for the southeastern jurisdiction is responsible for combating and preventing fraud, waste, and abuse in Alabama, Florida, Georgia, North Carolina, Puerto Rico, South Carolina, Tennessee, the U.S. Virgin Islands, Virginia, and West Virginia for the following types of claims:
• Parts A and B;
• DMEPOS; (durable medical equipment, prosthetics, orthotics, and supplies)
• Home health and hospice; and
• Claims for dually-eligible Medicare and Medicaid recipients.
The UPIC creates a focused resource to detect and deter fraud in the Medicare program. In this capacity, it develops administrative solutions, investigations, and cases for referral to law enforcement, as well as providing ongoing support to law enforcement as needed. Additional responsibilities include coordination of benefit integrity activities in the region and dissemination of relevant benefit integrity information to other Medicare contractors, health care providers, and Medicare recipients.
SGS continues its partnership with IntegriGuard LLC as its subcontractor to perform medical record reviews, financial reviews, and education activities as it did as the former ZPIC for zone 7. To further optimize its operations, SGS engages the services of several other subcontractors with specialized experience for various portions of the UPIC work as well as engaging a subcontractor to ensure operational standards are met.
The UPIC does not replace the Medicare program administration work that is performed by the Medicare administrative contractors. Their responsibilities include processing and paying claims, performing customer service, reviewing the medical necessity of claims unrelated to suspected fraud and abuse, and auditing facilities for Medicare expenses and reimbursement. As a note, complaints or allegations of suspected fraud or abuse should be reported to the Medicare contractors who process the claims for initial screening. Allegations of suspected fraud and abuse are brought to the attention of the UPIC only after the possibility of errors or misunderstandings are ruled out.
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