Unified Program Integrity Contractor (UPIC)

The goal of the UPIC is to identify cases of suspected fraud, investigate them, and take action to ensure any inappropriate Medicare payments are recouped.

Fraud may include things such as:

  • Billing for services not furnished
  • Billing that appears to be deliberate for duplicate payment
  • Altering claims or medical records to obtain a higher payment amount
  • Soliciting, offering, or receiving a kickback or rebate for patient referrals
  • Billing non-covered or non-chargeable services as covered

UPIC actions to detect and deter fraud and abuse may include:

  • Investigating potential fraud and abuse, including interviews and onsite visits
  • Perform medical review, as appropriate
  • Perform data analysis
  • Identify the need for administrative actions, such as payment suspensions and prepayment, or auto-denial edits
  • Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution.

For additional contact information, refer to the "Review Contractor Directory – Interactive MapExternal Website" link on the CMS website.

Additional Resources

Updated: 11.29.18

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