What is a UPIC Audit and How to Prepare for One?

Durable Medical Equipment (DME) suppliers should be prepared and ready for a Unified Program Integrity Contractors (UPIC) audit. Medicare regulation is an extensive program, and being prepared before an audit can save you time and resources. 

Unified Program Integrity Contractors (UPIC) Audits Goal

The Centers for Medicare and Medicaid Services (CMS) created the UPIC audits to identify and stop fraud and abuse in Medicare and Medicaid. 

The main goal of UPIC is to help CMS:

  • Find fraud, abuse, and waste
  • Perform regional Medicare and Medicaid data analysis 
  • Complaint resolution 
  • Investigate suspected fraud activities 

The UPIC uses the above and additional techniques to identify Medicare and Medicaid program weaknesses and vulnerabilities. 

Fraud vs. Abuse

Since UPIC audits search for fraud and abuse, it’s essential to understand the difference between them.


Fraud is purposely misleading other people or facts for specific reasons. This can include personal benefit, someone else’s benefit, or a company/organization. 


Abuse is when a person or company’s actions are not acceptable with sound medical, business, or fiscal practices. This results in wasted costs and improper payments. 

Takes Resources Away from Others 

Both fraud and abuse diminish the Medicare Trust Fund resources for others who need it. 

Medicare Administrative Contractor’s Working with UPIC 

The Medicare Administrative Contractor (MAC) is in charge of all other responsibilities assigned to the UPIC by the Statement of Work.

MAC responsibilities include:

  • Appeals
  • Claims processing 
  • Customer service 
  • Financial accounting 
  • Medicare Secondary Payer education
  • Refer suspected fraud and abuse to the UPIC 
  • Provider enrollment 
  • Selecting prepayment and post-payment medical review functions

To learn more read our article, “Are you Prepared for DME MAC Contractor Audits?”

Who is at Risk for an Audit?

Typically, UPIC audit selection is based on consumer complaints or data analysis. A consumer complaint comes from the company’s employees or the beneficiaries.

Meanwhile, data analysis will search for a large number or mix of cases. Those cases will involve patients who’ve received hospice care, stayed in acute care facilities or had extended home visits. 

3 Tips to Prepare for a UPIC Audit

If you are being audited or want to be ready, here are three ways to prepare for a UPIC audit. 

1. Develop a Plan 

Having a plan in place will ensure you don’t miss any crucial steps in an audit. It can also help spot any potential errors within your system and correct them before an error occurs.

The most important part is to ensure everyone understands the regulatory and statutory provisions for Medicare services. Take these steps:

  • Check system coding, documentation, and billing practices
  • Look for inconsistencies 
  • Correct any errors found 
  • Create a plan to prevent the same mistakes from occurring again 

2. Respond Timely to UPIC Requests

If you fail to provide a timely response for requested documentation, it could result in suspension from participating in the Medicare program. 

3. Stay Educated on Medicare Requirements 

Keep yourself and your staff educated on Medicare’s coding and billing requirements. Have an education process set up for new employees and even have a “refresher” course for all employees. This process should outline and educate everyone on the records management procedures. 

Remember preventing mistakes upfront is a much faster and easier solution than correcting the errors after they occur.

Stay Educated with Medbill’s Assistance 

An essential part of any audit is preparation. Becoming and staying prepared in the event of a UPIC audit can make a world of difference.

The Medbill DME Billers team can review ALL claims before they are sent to the Payor. They will ensure the claims are reviewed for Policy Compliance. And your staff is alerted to any claims that may be missing documentation or might be susceptible to an audit. Learn more about Medbill’s Audit Assist Services here.

If you’re ready to talk to a Medbill team member, contact us here