![]() ![]() This may include “upcoding” in which a provider/supplier deliberately misrepresents procedures or diagnoses in order to maximize reimbursement, “double billing” in which providers/suppliers bill Medicare and a patient or other insurer for the same service or item, and “phantom billing” in which a bill is submitted for services or items a patient never received. ![]() While UPICs work on program integrity activities such as waste and abuse, most of their work is focused on fraud. However, CMS is authorized to adjust payments to UPICs if their workloads increase significantly and to award individual performance-based bonus payments. Unlike RACs, which receive a percentage of the improper payments they identify, UPICs do not work on a contingency basis. Annual funding for each of the five individual UPICs ranged from $16.5 million to $24.5 million in 2019, but a five-year contract extension awarded to one UPIC in 2022 for $154 million indicates that program funding is increasing. UPICs work under indefinite delivery, indefinite quantity (IDIQ) contracts, with funding for each UPIC based on the jurisdiction’s historic workload. While there is only one UPIC per region, a UPIC may be awarded contracts for multiple jurisdictions. UPICs, which have only been in existence since 2016, and which have assumed responsibilities previously performed by Zone Program Integrity Contractors (ZPICs) and Medicaid Integrity Contractors (MICs), are charged with deterring fraud, waste and abuse in Medicare Parts A and B, Durable Medical Equipment (DME), Home Health, Hospice, Medicaid and the Medicare-Medicaid (Medi-Medi) data match programs.ĬMS contracts with a single UPIC for each of five geographic jurisdictions: Midwest, Northeast, West (inclusive of American Samoa, Guam, and the Northern Mariana Islands), Southeast (inclusive of Puerto Rico and the Virgin Islands), and Southwest. RACs, which were established under the Medicare Prescription Drug, Improvement and Modernization Act of 2003, are charged with identifying and correcting improper payments made under Medicare Parts A and B. But their mission, jurisdictions, and tactics are different. Like RACs, UPICs are independent contractors, working on behalf of CMS to protect government healthcare program payments. ![]()
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