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UPIC Audits

UPIC & ZPIC Audit Defense Attorneys | Nationwide Representation

Defending Healthcare Providers Against Qlarant, SafeGuard & CoventBridge Investigations

The Centers for Medicare & Medicaid Services (CMS) created the Unified Program Integrity Contractors (UPIC) program to investigate suspected fraud and abuse in both Medicare and Medicaid programs. UPICs investigate Medicare Parts A and B, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), as well as Medicaid providers and managed care organizations. 

If you get a letter from a UPIC requesting medical records, you are already under investigation. UPICs, such as Qlarant and SafeGuard Services, do not conduct random audits. They initiate focused reviews, medical record requests, and interviews to gather evidence and establish the facts in suspected cases of Medicare fraud, waste, or abuse.

Call (713) 783-3110 to get started on your defense. Our experienced attorneys represent healthcare providers nationwide facing UPIC investigations from Qlarant, SafeGuard Services, and CoventBridge.

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A UPIC/UPIC auditor reviews Medicare billing records on her computer for patterns that may indicate healthcare fraud

How We Protect Healthcare Providers During UPIC Investigations

Hendershot Cowart P.C. represents healthcare providers, physicians, DME suppliers, home health agencies, hospice centers, and medical practices throughout the United States facing UPIC investigations.

Our goal when representing clients in UPIC investigations is to protect your practice, your livelihood, and your professional reputation.

Without experienced legal counsel, providers facing UPIC investigations often:

  • Submit documentation that raises more questions than it answers
  • Make statements to auditors that strengthen fraud allegations
  • Miss critical deadlines that forfeit appeal rights
  • Accept unfavorable settlements out of fear or exhaustion
  • Face payment suspensions lasting 12-18 months or longer
  • Suffer recoupment demands in the millions due to extrapolation

With Hendershot Cowart's UPIC defense representation:

We Control the Investigation Narrative. From day one, we shape how the UPIC understands your case – presenting your billing practices in the most favorable light while addressing alleged violations strategically.

We Prepare You for Every Interaction. Before you speak with any UPIC investigator, we ensure you understand exactly what to say and what to avoid. Our attorneys attend all interviews and site visits to protect your rights.

We Challenge Unfair Findings Aggressively. UPICs are incentivized to find make erroneous conclusions or use flawed extrapolation methodologies, we don't accept them quietly. We challenge findings with expert testimony, statistical analysis, and aggressive legal advocacy.

We Negotiate Better Outcomes. Whether it's preventing payment suspensions, reducing recoupment demands, or securing favorable settlement terms, we leverage our experience to achieve outcomes that protect your financial stability.

We Prevent Criminal Referrals. Our most important role is often what doesn't happen – preventing your case from being referred to the DOJ, FBI, or OIG for criminal prosecution. We monitor healthcare investigations closely and intervene strategically to demonstrate billing errors rather than fraudulent intent.

We Guide You Through Appeals. If your case requires appeals through Medicare’s multi-level appeals process, we're with you for the entire journey – from initial redetermination through federal court if necessary. We don't hand you off to another attorney at each stage.

We Help You Survive Financially. Payment suspensions can destroy practices within months. We work aggressively to get suspensions lifted, negotiate partial payment releases, and accelerate resolution timelines so you can keep your doors open.

Nationwide UPIC Audit Defense Representation

We defend providers against all UPIC contractors:

  • Qlarant Integrity Solutions – Covering the Western and Southwestern jurisdictions (Alaska, Arizona, California, Colorado, Texas, and 18 other states)
  • SafeGuard Services, LLC – Covering the Southeastern and Northeastern jurisdictions (Florida, New York, Pennsylvania, Virginia, and 15 other states)
  • CoventBridge (USA) Inc. – Covering the Midwest jurisdiction (Illinois, Ohio, Michigan, and 8 other states)

Qlarant, SafeGuard, and other UPIC auditors are not interested in helping you; they are interested in aggressively rooting out evidence of waste and abuse to preserve their government contracts.

You need someone on your side, too.

What Should I Do If I Receive a Letter from a UPIC, Such as Qlarant?

If you receive a letter from a UPIC, you are already under investigation. This is no ordinary Medicare audit. Your case has been escalated to a federal fraud investigation, so take allegations and requests for information seriously.

Take these immediate actions:

1. Do Not Ignore the Letter

UPIC document requests include strict deadlines – typically 10-45 business days. Missing these deadlines can result in automatic adverse determinations, payment suspensions, or billing privilege revocation.

2. Do Not Respond Without Legal Counsel

Anything you submit to a UPIC can be used against you in administrative proceedings or criminal prosecution. 

3. Retain a UPIC Audit Defense Attorney Immediately

Your attorney can help you present the requested documentation – on time and within the requested parameters – while protecting you from fraud, waste, or abuse allegations that could open you up to further investigations from the OIG, FBI, or Department of Justice.

4. Preserve All Relevant Documents

Once you receive a UPIC letter, you have a legal duty to preserve all relevant documents, including:

  • Patient medical records
  • Billing records and claim submissions
  • Staff communications about billing practices
  • Emails and internal memos
  • Compliance policies and training materials

Destroying or altering documents after receiving a UPIC investigation notice can result in criminal obstruction charges.

5. Do Not Discuss the UPIC Investigation Publicly

Avoid discussing the UPIC investigation with staff, patients, or colleagues beyond those who need to know. Information shared can be discovered through interviews and subpoenas.

If you fail to fully and completely respond to the initial request, Qlarant or SafeGuard will escalate the situation, and the consequences could include immediate payment suspension, extrapolated recoupment demands, or referral to federal law enforcement.

Call Hendershot Cowart at (713) 783-3110 the day you receive a UPIC letter. Early legal intervention significantly improves your chances of a favorable outcome.

What to Expect from a UPIC Audit

When investigating a provider, a UPIC auditor may:

  • Request medical records and documentation
  • Conduct interviews with patients, complainants, staff, or providers
  • Visit your practice
  • Identify the need for a prepayment or auto-denial edit
  • Institute a provider payment suspension
  • Refer potential fraud cases to law enforcement

UPICs evaluate medical records for evidence of alterations, such as missing pages, inserted pages, or unsigned and undated handwritten notes in margins. They look for patterns or trends, such as overuse of high-end codes or billing for more hours of care than would normally be expected. And they will conduct interviews to verify that services or equipment were provided as claimed.

What Triggers a UPIC Audit?

UPICs don't conduct random audits. Investigations are triggered by billing anomalies, referrals from Recovery Audit Contractors (RACs) or Medicare Administrative Contractors (MACs), OIG complaints, data mining that reveals unusual billing patterns, or tips from whistleblowers.

Hospice care, home health agencies, long-term care, and durable medical equipment (DME) providers are especially vulnerable to UPIC investigations. 

Common triggers for UPIC investigations include:

  • Having a greater frequency of high-end services compared to local or national patterns
  • Billing trends that fall outside of the industry standard
  • Long inpatient stays (hospice providers and long-term care providers are most at risk)
  • Claim records that do not match doctor’s records
  • Medical records that tend to have obvious or nearly identical documentation
  • Any improper or inaccurate Medicare billing
  • Complaints to the OIG
  • Referrals from other government contractors (RACs or MACs) or investigative agencies
  • OIG and FBI inquiries

Perform internal audits regularly to catch potential triggers and double-check that your medical records comply with state and federal regulations. They should be patient-specific, legibly signed by the rendering provider, and note the intent to order services and procedures, among other medical record documentation requirements.

Medicaid Audit Defense: UPIC Investigations for Medicaid Providers

While UPICs are widely known for Medicare audits, Medicaid providers, such as home health services providers, face equally aggressive UPIC investigations. If you're a Medicaid provider who received a Qlarant or SafeGuard letter, you're under federal investigation – even though Medicaid is state-administered.

How Medicaid UPIC Audits Work

UPICs investigate Medicaid fraud under federal oversight, even though Medicaid programs are state-run. This creates complex jurisdictional issues where providers face both federal and state scrutiny simultaneously.

Common Medicaid UPIC audit triggers include:

  • Managed care organization (MCO) billing irregularities
  • Personal care services documentation deficiencies
  • Home and community-based services (HCBS) compliance issues
  • Duplicate billing across Medicare and Medicaid
  • Provider enrollment fraud or misrepresentation
  • Excessive utilization patterns compared to peer providers

Medicaid Audit Defense Strategy

Our healthcare attorneys defend Medicaid providers in all 50 states against UPIC investigations by:

  • Analyzing state-specific Medicaid requirements that UPICs may misinterpret
  • Coordinating responses to both UPIC and state MFCU inquiries
  • Challenging recoupment demands based on documentation standards
  • Preventing referrals to state and federal law enforcement
  • Protecting your enrollment in both Medicare and Medicaid programs

If you're a Medicaid provider facing a UPIC audit, don't assume the rules are the same as Medicare. The complexities of Medicaid compliance require experienced legal guidance.

ZPIC Audit Defense: Understanding the Predecessor to UPIC

If you're searching for information about ZPIC audits, you need to know that Zone Program Integrity Contractors (ZPICs) no longer exist. In 2016, CMS transitioned from the ZPIC program to the current UPIC program. However, the investigative approach, severity, and consequences remain essentially the same.

What Was a ZPIC Audit?

ZPIC audits were CMS's most aggressive fraud detection tool from 2009 to 2016. ZPICs investigated Medicare Parts A and B, DME, Home Health and Hospice providers suspected of fraud, waste, or abuse. These were not routine compliance audits – ZPIC involvement meant CMS had credible evidence of potential fraud.

ZPIC Audit Consequences Are Now UPIC Consequences

The administrative actions that ZPICs could impose are identical to UPIC powers:

  • Payment suspension during investigation
  • Prepayment review or auto-denial edits
  • Recoupment of alleged overpayments
  • Revocation of Medicare billing privileges
  • Referrals to DOJ, FBI, or OIG for criminal prosecution

Bottom line: If you're researching ZPIC audits because you received an investigation notice, you're actually dealing with a UPIC audit. The name changed, but the stakes remain just as high.

The Medicare Appeals Process: Your Rights After an Adverse UPIC Determination

Not all UPIC decisions are final. Some types of UPIC determinations trigger your Medicare and Medicaid appeal rights:

  • Overpayment Determinations – When a UPIC concludes you were overpaid and demands recoupment, often with significant interest penalties.
  • Payment Suspensions – When CMS suspends your Medicare/Medicaid payments during an ongoing investigation based on UPIC recommendations.
  • Revocation of Billing Privileges – When CMS revokes your ability to bill Medicare based on UPIC audit findings.

The Medicare appeals process involves up to five levels of review. At each level, you must meet strict deadlines and procedural requirements, making experienced legal counsel essential.

Learn more about the five levels of the Medicare appeals process. 

Facing a UPIC Investigation Anywhere in the U.S.? Contact Experienced Healthcare Attorneys.

Hendershot Cowart P.C. delivers immediate responsive representation to healthcare providers nationwide facing Medicare and Medicaid UPIC audits or fraud investigations. Our skilled healthcare law attorneys have more than 100 years of collective legal experience defending providers against Qlarant, SafeGuard, and CoventBridge investigations throughout the United States.

We represent clients in all 50 states. From California to New York, Florida to Illinois, our attorneys understand federal healthcare regulations, Medicare/Medicaid billing requirements, and the UPIC audit process regardless of your practice location.

We are committed to the success and well-being of your practice. Call Hendershot Cowart P.C. at (713) 783-3110 or contact us online to discuss your UPIC investigation – no matter where you practice.

Medicare UPIC Audit FAQ

What Does UPIC Stand For?

UPIC stands for Unified Program Integrity Contractor. UPICs are private contractors hired by CMS to investigate suspected fraud, waste, and abuse in Medicare and Medicaid programs.

What Is a UPIC Audit?

A UPIC audit is a focused fraud investigation, not a routine compliance review. If you receive a UPIC letter requesting medical records, you are already under investigation for suspected fraudulent billing or program abuse.

What Is a Qlarant Audit?

Sometimes providers get an audit request and don’t realize with whom they are dealing. Qlarant Integrity Solutions (Qlarant) is one of three UPIC contractors that conducts Medicare and Medicaid compliance audits.

If you get a letter from Qlarant, take it seriously. A Qlarant audit is a UPIC audit.

How Long Does a UPIC Audit Take?

UPIC audits typically last 6-12 months, though complex cases can extend longer. During this time, CMS may suspend your payments, creating severe financial pressure on your practice.

Can a UPIC Suspend My Medicare Payments?

Yes. UPICs have authority to recommend payment suspensions to CMS during investigations. Payment suspensions can last throughout the investigation and appeals process, which may take a year or more.

Do I Need a Lawyer for a UPIC Audit?

Yes. UPIC audits are fraud investigations with potentially career-ending consequences. An experienced healthcare attorney can help you respond properly to document requests, prepare for interviews, challenge unfair findings, and prevent criminal referrals.

Do You Represent Providers Outside of Texas?

Yes. We represent healthcare providers, physicians, DME suppliers, home health agencies, and medical practices in all 50 states facing UPIC audits from Qlarant, SafeGuard Services, or CoventBridge. UPIC investigations are federal matters governed by Medicare and Medicaid regulations, which are consistent nationwide.

What Are the Consequences of a UPIC Audit?

If a UPIC audit detects Medicare or Medicaid fraud, consequences can include:

  • Payment suspension during investigation
  • Prepayment review or auto-denial edits
  • Recoupment of alleged overpayments
  • Revocation of Medicare billing privileges
  • Referrals to the U.S. Department of Justice (DOJ), Federal Bureau of Investigation (FBI), or the U.S. Department of Health and Human Services Office of Inspector General (OIG) for criminal prosecution

Don't Face a UPIC Investigation Alone

UPIC audits move quickly, and delayed responses can result in payment suspensions, recoupment demands, or criminal referrals. The sooner you involve experienced legal counsel, the better your chances of a favorable outcome.

Our healthcare attorneys are ready to defend your practice against Qlarant, SafeGuard, or CoventBridge investigations – no matter where you practice.

Call (713) 783-3110 today or contact us online for a confidential consultation about your UPIC audit.

Why Choose Our Team?

Unwavering Commitment to the Success of our Clients

With over 100 years of combined experience, we bring big firm expertise with personal firm service. Whether facing multi-jurisdictional litigation or regulatory issues, we stand by your side, fighting for your success.

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