Unified Program Integrity Contractor

4.2.2.1 - Unified Program Integrity Contractor (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The UPIC is responsible for preventing, detecting, and deterring fraud, waste, and abuse in both the Medicare program and the Medicaid program. The UPIC: • Prevents fraud by identifying program vulnerabilities; • Proactively identifies incidents of potential fraud, waste, and abuse that exist within its service area and takes appropriate action on each case; • Investigates (determines the factual basis of) allegations of fraud made by beneficiaries, providers/suppliers, CMS, OIG, and other sources. When appropriate, the UPIC may collaborate with CMS, State Medicaid Agency (SMA), and MFCU personnel; • Explores all available sources of fraud leads in its jurisdiction, including the SMA and the Medicaid Fraud Control Unit (MFCU); • Initiates appropriate administrative actions where there is reliable evidence of fraud, including, but not limited to, payment suspensions and revocations; • Refers cases to the OIG/Office of Investigations (OI) for consideration of civil and criminal prosecution and/or application of administrative sanctions (see section 4.9 of this chapter, as well as PIM, chapter 8); • Refers any necessary provider/supplier and beneficiary outreach to the provider outreach and education (POE) staff at the MAC; • Initiates and maintains networking and outreach activities to ensure effective interaction and exchange of information with internal components as well as outside groups; • Partners with state Medicaid PI units to perform the above activities in suspected Medicaid fraud, waste, and abuse cases (including Medi-Medi cases); or • Works closely with CMS on joint projects, investigations and other proactive, anti-fraud activities. The UPIC is required to use a variety of techniques, both proactive and reactive, to address any potentially fraudulent, wasteful, or abusive billing practices based on the various leads they receive. Proactive leads are leads identified or self-initiated by the UPIC. Examples of proactive leads include, but are not limited to: (1) UPIC data analysis that uncovers inexplicable aberrancies that indicate potentially fraudulent, wasteful, or abusive billing for specific providers/suppliers; (2) the discovery of a new lead by a UPIC during a provider/supplier or beneficiary interview; and (3) the combining of information from a variety of sources to create a new lead. The UPIC shall pursue leads identified through data analysis (UPICs shall follow PIM Chapter 2, Section 2.3 for sources of data), the Internet, the Unified Case Management system (UCM), news media, industry workgroups, conferences, etc. For workload reporting purposes, the UPIC shall only identify as proactive those investigations and cases that the UPIC self-initiated. The UPIC shall take prompt action after scrutinizing billing practices, patterns, or trends that may indicate fraudulent billing, (i.e., reviewing data for inexplicable aberrancies and relating the aberrancies to specific providers/suppliers, identifying “hit and run” providers/suppliers, etc.). Fraud leads from any external source (e.g., LE, CMS referrals, beneficiary complaints, and the FPS) are considered to be reactive and not proactive. However, taking ideas from external sources, such as Fraud Alerts, and using them to look for unidentified aberrancies within UPIC data is proactive.