CMS Pub. 100-15, ch. 1, § 1.2

The UPICs are contracted entities with CMS that conduct investigations/audits (which

may be referred to as “reviews” by certain state Medicaid agencies) of providers’ billing

in an effort to reduce fraud, waste, and abuse in both the Medicare and Medicaid

programs. The UPICs operate in geographic areas or “jurisdictions” defined by individual

Task Orders.

The UPICs perform numerous functions to detect, prevent, and deter specific risks and

broader vulnerabilities to the integrity of the Medicare and Medicaid programs including,

but not limited to:

• Proactively identify potential fraud, waste, and abuse that exist within its service

area and take appropriate action on each case.

• Investigate allegations of fraud made by beneficiaries, providers/suppliers, CMS,

Health & Human Services Office of Inspector General (HHS-OIG), social media

and other sources.

• Jointly operate with other entities through agreements in the analysis of data,

medical review and/or other specialty areas.

• Explore all available sources of leads, including, but not limited to, state

Medicaid agencies (SMAs), law enforcement, CMS’ Center for Program

Integrity or its Regional Offices, social media, and the contractor’s own data

mining.

• Refer and/or recommend appropriate Medicaid administrative actions to the

SMAs based on investigative/audit findings including, but not limited to:

overpayments, payment suspensions, terminations, referrals to licensing boards,

etc.

• Refer cases that aligns with the Medicaid Major Case Coordination process to

the HHS-OIG/Office of Investigations (OI) for consideration of civil and

criminal prosecution and/or application of administrative sanctions.

• Partner with state Medicaid Program Integrity Units to perform the above

activities for Medicaid investigations/audits.

• Work closely with CMS on joint projects, investigations/audits, and other

proactive, anti-fraud activities.

The UPICs utilize a variety of techniques to address any potentially fraudulent, wasteful,

or abusive billing practices based on the various leads they receive. The UPICs integrate

the program integrity functions for investigations/audits across Medicare and Medicaid

and assure that CMS’s national priorities for both Medicare and Medicaid are executed

and supported at the state level or within the UPIC jurisdiction.