Is Consolidation Coming to Anti-Fraud Contractors?


Consolidation has become a part of everyday life, covering everything from hospitals to department stores, and it may be coming to health-care anti-fraud contractors as well. For example, the Unified Program Integrity Contractor (UPIC) program is rolling four anti-fraud programs into one program.

The UPICs are intended to replace Zone Program Integrity Contractors (ZPICs), Program Safety Contractors (PSCs), the Medicare-Medicaid data match program (Medi-Medi) and Medicaid Integrity Contractors (MICs). Seven contracts were awarded in August 2016, and AdvanceMed, owned by NCI Information Systems Inc. and based in Reston, Va., was awarded the program's first task order for $76.8 million.

I spoke with several attorneys who told me that consolidation could benefit providers by creating a more uniform policy guidance for anti-fraud contractors. “The idea of UPIC consolidation was to improve the efficiency of program integrity work, and part of the consolidation plan was the creation of a unified case management system so that the contractors weren't duplicating work or stepping on each other's cases,” Ellyn Sternfield, a health-care attorney with Mintz Levin, told me.

Sternfield said Medicare and Medicaid program integrity have had some uneven results, bolstering the case for consolidation. Sternfield said there have been questions about the data sources used by MICs, and said many of them don’t seem to understand that the individual states set Medicaid billing requirements, not the Centers for Medicare & Medicaid Services, and that state requirements change regularly.

AdvanceMed’s task order covers the Midwest jurisdiction and is focused on fraud lead screening, investigation, medical reviews and collaborating with the CMS and state and local government and law enforcement. The Midwest jurisdiction covers Illinois, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Missouri, Nebraska, Ohio and Wisconsin.

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