van Halem: 'Aggressive' UPICs take over

ATLANTA - It's time for HME providers to reacquaint themselves with the Unified Program Integrity Contractors, or UPICs, says Wayne van Halem. CMS announced plans to create this new program integrity contractor years ago, but after numerous protests and transitions, the UPICs are only now “fully operational,” says van Halem, president of The van Halem Group. Here's what he had to say about where the UPICs are looking first.

HME News: Who are the UPICs?

Wayne van Halem: There are three contractors for five jurisdictions. AdvanceMed for Jurisdiction 1 (Midwest); Qlarant for Jurisdictions 2 (Western) and 3 (Southwest); and Safeguard Services for Jurisdictions 4 (Southeast) and 5 (Northeast).

HME: What kind of audits are they conducting?

van Halem: They're doing both pre- and post-pay audits. We like to use the term audit, but they use the term investigation. They're doing fraud investigations.

HME: Are they focusing on any specific product categories right now?

van Halem: They seem to be focused on orthotic braces, because there are a lot of issues going on there related to telehealth or lead generation, and the volume is high. We've also seen some audits involving vents.

HME: So high volume can trigger these audits?

van Halem: They're heavily using claim data analysis, so yes, they're looking for spikes in billing. But they're also basing their audits on complaints from patients and referrals from other contractors for companies, for example, that go through the TPE process and fail.

HME: How do the UPICs compare to other auditors?

van Halem: They're much more aggressive and seem to be doing a lot more payment suspensions. Also, one of the things they're doing now is, when a UPIC in one jurisdiction implements a payment suspension, all of them initiate a post-payment audit. We've had providers go through this. There's a suspension from one contractor then a letter from all the other contractors requesting claims to review, and then each identifies an extrapolated overpayment. Before, with the ZPICs, there was usually one extrapolated overpayment to deal with.

HME: Does their aggressiveness have to do with the size of their contracts? Safeguard, for example, is getting about $130 million for its contract for the Southeast.

van Halem: They have to show CMS a return on investment and the investment is significant. When they do a payment suspension, that's quantified as savings. When they extrapolate an overpayment, that quantifies as savings.

HME: Do providers have any avenues of recourse?

van Halem: The UPICs certainly don't make it easy. Most of the time, they provide a main phone number where you can leave a message and hope someone gives you a call back. If they do call you back, they often refuse to give you information. They don't necessarily want to communicate and they don't have to.